med/surg chap 14
A client has been NPO after a colectomy with nasogastric (NG) suction in place. On assessment, the nurse finds the client reporting cramps in the calves. Which action by the nurse is most appropriate?
Raise the siderails and notify the physician.
The nurse expects to find renal compensation for an acid-base imbalance in which situation?
Hypoxemia for 4 days from pneumonia in an adult woman
The nurse is providing discharge teaching. Which statement by the client indicates the need for further teaching regarding increased risk for metabolic alkalosis?
"I take sodium bicarbonate after every meal to prevent heartburn."
A client is being discharged and continues to be at risk for developing metabolic alkalosis. Which statement by the client indicates to the nurse that teaching has been effective?
"I will avoid excess use of antacids."
Which client does the nurse assess for potential metabolic acidosis?
Young adult following a carbohydrate-free diet
The nurse prepares to administer bicarbonate intravenously to the client with which clinical manifestations?
pH 7.28, HCO3- 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea
The nurse interprets which arterial blood gas values as partially compensated metabolic acidosis?
pH 7.32, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg
A client has respiratory acidosis. The nurse evaluates that treatment is being effective with which arterial blood gas values?
pH 7.35, HCO3- 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg
A client is admitted with mixed respiratory and metabolic acidosis secondary to bronchitis and diabetic ketoacidosis. The nurse evaluates that teaching about the client's confusion was effective when a family member makes which statement?
"The confusion should clear when oxygen and electrolyte levels are normal."
The nurse monitors the client with which condition most carefully for metabolic alkalosis?
A critical illness receiving total parenteral nutrition
A client has an arterial blood gas pH of 7.48. How does the nurse interpret this client's acid-base status?
A deficit in blood hydrogen ion concentration
The nurse monitors for which acid-base problem in a client who is taking furosemide (Lasix) for hypertension?
Acid deficit secondary to metabolic alkalosis
A client has been placed on a ventilator. The physician has ordered that the ventilator be set to deliver a respiratory rate set of 28 breaths/min. The nurse questions the order, citing concerns about which acid-base problem?
Acid deficit: alkalosis
In a client 4 minutes post cardiac arrest, the nurse correlates the largest source of excess hydrogen ions with which cause?
Anaerobic metabolism, leading to the buildup of lactic acid
The nurse correlates which condition with the following arterial blood gas values: pH 7.48, HCO3- 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?
Anxiety-induced hyperventilation
A client has just experienced a 90-second tonic-clonic seizure and has these arterial blood gas values: pH 6.88, HCO3- 22 mEq/L, PCO2 60 mm Hg, PO2 50 mm Hg. Which intervention by the nurse is most appropriate?
Apply oxygen by mask or nasal cannula.
The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour ago. What action does the nurse take next?
Assess client's rate, rhythm, and depth of respiration.
A client has moderate metabolic alkalosis. What is the priority intervention for the nurse?
Assess the client's muscle strength.
A client has the following arterial blood gases (ABGs): pH 7.30, HCO3- 22 mEq/L, PCO2 55 mm Hg, PO2 86 mm Hg. Which intervention by the nurse takes priority?
Assessing the airway
A client has the following arterial blood gases: pH 7.30, HCO3- 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg. Which intervention by the nurse is most appropriate?
Assist the physician in determining the cause.
A client who was malnourished is being discharged. The nurse evaluates that teaching to decrease risk for the development of metabolic acidosis has been effective when the client states, "I will:
Be sure to eat three well-balanced meals and a snack daily."
The nurse reads in the medical record that a client has Kussmaul respirations. Which assessment finding is consistent with this condition?
Deep, rapid respirations
The nurse monitors for which acid-base imbalance in a client who has hypoxemia?
Excess carbon dioxide production leading to acidosis
Which response is an example of compensation for an acid-base imbalance?
Increase in the rate and depth of respirations when exercising
In the client with hypoventilation, which change in arterial blood gases does the nurse evaluate to determine whether treatment measures are being effective?
Increased arterial blood bicarbonate
A client is in the emergency department after an overdose of an unknown substance. Which assessment findings does the nurse correlate with possible salicylate poisoning?
Increased rate and depth of respiration
In a client with less than the normal amount of bicarbonate in the blood and other extracellular fluids, what response does the nurse anticipate?
Increased risk for acidosis
A client has metabolic alkalosis. Which laboratory results is the nurse most likely to assess as consistent with this condition?
K+ 3.1 mEq/L
A client has acute pancreatitis and a risk for acid-base imbalance. The nurse plans to assess for which manifestation consistent with this condition?
Kussmaul respirations
A client has a prolonged fever. For which acid-base imbalance does the nurse assess the client further?
Metabolic acidosis from increased production of hydrogen ions
A postoperative client received six units of packed red blood cells (PRBCs) for intraoperative blood loss. The nurse monitors the client for which acid-base imbalance?
Metabolic alkalosis
A client with chronic respiratory acidosis is receiving oxygen by nasal cannula at 6 L/min. The client's respiratory rate is 8 breaths/min. Which action by the nurse is the priority?
Notify the Rapid Response Team and prepare for intubation.
The nurse assesses the client with which condition most carefully for the risk of developing acute respiratory acidosis?
On patient-controlled analgesia after abdominal surgery
In the client with alkalosis, the nurse assesses for which clinical manifestations? (Select all that apply.)
Positive Chvostek's sign Positive Trousseau's sign Bradycardia
In clients with any type of acid-base imbalance, the nurse places the priority on monitoring which electrolyte?
Potassium
A client has acidosis. Which laboratory finding is of greatest concern to the nurse?
Potassium 5.9 mEq/L
When a client has an arterial blood pH of 7.48, which buffer action will bring the pH back to normal?
Release of hydrogen ions into the blood
A client is being discharged from the emergency department with several broken ribs. For which acid-base imbalance does the nurse provide discharge teaching?
Respiratory acidosis from inadequate ventilation
A client has mild acidosis but after a day has not compensated for it. Which action by the nurse is best?
Review the client's daily hemoglobin and hematocrit.
A client has severe metabolic alkalosis. Which nursing diagnosis does the nurse choose as the client's priority problem?
Risk for injury related to increased neuronal sensitivity from hypocalcemia
The nurse assesses for acidosis in the client with which assessment data?
Serum potassium level of 6.5 mEq per liter and flaccid paralysis
In evaluating the electrocardiogram (ECG) in a client with acidosis, the nurse correlates which ECG change with effectiveness of therapy?
T-waves present, normal height
A client has moderate acidosis. Which assessment does the nurse perform first?
Take the client's pulse and blood pressure, and analyze the electrocardiogram (ECG) strip.
A client has the following arterial blood results: pH 7.12, HCO3- 22 mEq/L, PCO2 65 mm Hg, PO2 56 mm Hg. The nurse correlates these values with which clinical situation?
Tracheal obstruction related to aspiration of a hot dog
