MyLab concept of Acid-Base Balance/Metabolic Acidosis/ Metabolic Alkalosis/ Respiratory Acidosis/ Respiratory Alkalosis NCLEX-style Questions
The nurse is teaching an adult client on the cause of metabolic acidosis. Which cause would the nurse include in the client education? (Select all that apply.) A. Acute diarrhea B. Tissue hypoxia C. Diabetes mellitus D. Chronic renal failure E. Potassium-wasting diuretics
A,B,C,D Rationale: Diabetes mellitus can develop into diabetic ketoacidosis. Tissue hypoxia can alter electrolytes and cause metabolic acidosis. Chronic renal failure can lead to metabolic acidosis. Acute diarrhea alters the acid-base balance in the body and can cause metabolic acidosis. The use of potassium-wasting diuretics may cause metabolic alkalosis, not acidosis.
Which independent nursing intervention is most appropriate for the nurse to include in the plan of care for a client to prevent metabolic acidosis? A. Assess renal and respiratory function. B. Perform continuous telemetry monitoring. C. Administer intravenous sodium bicarbonate. D. Obtain arterial blood gases daily.
A Rationale: An independent nursing intervention is one that can be performed without a healthcare provider's order. The nurse can assess the client's renal and respiratory function without an order. Arterial blood gases, continuous telemetry monitoring, and intravenous fluids cannot be done without an order.
A toddler-age client returns from the postanesthesia care unit (PACU) after having an appendectomy. Upon assessment, the nurse notes a dysrhythmia on the child's ECG and a positive Trousseau sign. The client is diagnosed with metabolic alkalosis. Which nursing intervention is the most appropriate for this client? A. Place the client in high-Fowler position. B. Weigh the client every other day. C. Monitor for bradycardia. D. Assess respiratory status every shift.
A Rationale: A client who is diagnosed with metabolic alkalosis will require positioning in Fowler or high-Fowler position to decrease the work of breathing. Respiratory status should be monitored every 2 hours, the client should be weighed every day, and the nurse should monitor for tachycardia, not bradycardia.132q
A client is diagnosed with metabolic alkalosis. Which healthcare prescriber's order should the nurse expect to assist in restoring this imbalance? A. Administer potassium chloride. B. Administer IV insulin. C. Administer sodium bicarbonate. D. Administer a bronchodilator.
A Rationale: In metabolic alkalosis, the administration of potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions. Sodium bicarbonate is used to treat metabolic acidosis, not metabolic alkalosis. IV insulin is used to treat diabetic ketoacidosis, which occurs with metabolic acidosis, not metabolic alkalosis. Bronchodilators are used to treat respiratory acidosis, not metabolic alkalosis.
A nurse is caring for a client whose arterial blood gas (ABG) results are as follows: pH 7.47 PCO2 35 PO2 90 HCO3 35 Which pharmacological therapy will the nurse anticipate administering for this client to help restore the client's acid-base balance? (Select all that apply.) A. Sodium chloride B. Calcium chloride C. Potassium chloride D. Magnesium chloride E. Ammonium chloride
A , C, E Rationale: This client has metabolic alkalosis. Pharmacological therapy for this condition includes potassium chloride, sodium chloride, and ammonium chloride. The potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions more effectively. Chloride promotes renal excretion of bicarbonate. Sodium chloride solutions restore fluid volume deficits that can contribute to metabolic alkalosis. In severe alkalosis, an acidifying solution such as ammonium chloride may be administered. While this client may have other electrolyte imbalances, magnesium chloride and calcium chloride are not typical therapies for the treatment of metabolic alkalosis.
The nurse is reviewing the arterial blood gases (ABGs) results of a client who has reported vomiting for the past 10 days. Which result should the nurse report to the to the healthcare provider? (Select all that apply.) A. pH 7. 51 B. HCO3 32 mEq/L C. PaCO2 51 mmHg D. PO2 92 mmHg E. O2 saturation 98%
A,B,C Rationale: A client with prolonged vomiting is at risk for metabolic alkalosis. The pH is elevated above the normal range of 7.35 to 7.45, which indicates the presence of alkalosis. The bicarbonate level is also elevated; the normal range is 22 to 26 mEq/L. The PaCO2 is elevated, indicating that respiratory compensation is occurring. These three values need to be reported to the healthcare provider. The PO2 and O2 saturation are both within the normal range and should be documented.
Which laboratory or diagnostic test is used to diagnose metabolic alkalosis? (Select all that apply.) A. ECG B. ABGs C. Urine pH D. Serum CBC E. Serum electrolytes
A,B,C, E Rationale: The laboratory or diagnostic tests used to diagnose metabolic alkalosis include: ABGs, ECG, serum electrolytes, and urine pH. A CBC (complete blood count) is not used to diagnose metabolic acidosis.
Which is a risk factor for the development of metabolic alkalosis? (Select all that apply.) A. Hypokalemia B. Hospitalization C. Gastric suctioning D. Primary hypoaldosteronism E. Treatment with alkalinizing solution
A,B,C,E Rationale: Risk factors for metabolic alkalosis include: hospitalization, hypokalemia, treatment with an alkalinizing solution, gastric suctioning, and primary hyperaldosteronism, not hypoaldosteronism. Metabolic alkalosis occurs when the body loses too much acid or gains too much base. Hypokalemia can contribute in more than one way to metabolic alkalosis; either secondary to the common causes of metabolic alkalosis such as vomiting and gastric suction, which result in acid loss or through further reabsorption of HCO3 when the body responds to hypokalemia. Metabolic alkalosis can occur more frequently in hospitalized clients due to various treatments or complications of the illness being treated
The nurse is assessing the arterial blood gases and a metabolic panel for a client with suspected metabolic alkalosis. Which finding would support this diagnosis? (Select all that apply.) A. pH 7.52 B. HCO3 30 mEq/L C. Serum potassium 4.6 mEq/L D. Serum chloride 90 mEq/L E. Urine pH 5
A,B,D Rationale: In metabolic alkalosis, the pH is greater than 7.45, HCO3 is greater than 26 mEq/L, and serum chloride may be decreased (less than 95 mEq/L). Serum potassium may also be decreased, thus a serum potassium of 4.6 mEq/L would not support a diagnosis of metabolic alkalosis. In metabolic alkalosis, urine pH is usually low (1-3).
The nurse is assessing an adult client who has been prescribed sodium bicarbonate as an antacid. Which side effect would the nurse discuss with the client? (Select all that apply.) A. Irritability B. Confusion C. Mood elevation D. Electrolyte imbalances E. Decreased respiratory rate
A,B,D,E Rationale: Adverse effects of sodium bicarbonate include confusion, irritability, decreased respiratory rate, and electrolyte imbalances. Mood elevation is not an adverse effect of sodium bicarbonate.
The nurse educator is explaining the relationship between acidity, alkalinity, and the pH of a solution. Which statement is most appropriate for the nurse educator to include in the teaching? (Select all that apply.) A. A pH of 7.0 is neutral. B. Bases are also called alkalis. C. An increase in hydrogen ions typically causes pH to increase. D. A decrease in hydrogen ions typically causes a decrease in pH. E. The pH is inversely proportionate to hydrogen ion concentration.
A,B,E Rationale: The pH is inversely proportionate to the concentration of hydrogen ions; that is, when the hydrogen ion concentration increases, the pH decreases. A pH of 7.0 is neutral. Bases are also called alkalis.
Which assessment finding would the nurse expect to find in a client with decreased cardiac output secondary to metabolic acidosis? (Select all that apply.) A. Hypotension B. Poor skin turgor C. Capillary refill > 5 seconds D. Bounding peripheral pulses E. 3+ pitting lower extremity edema
A,C Rationale: Decreased cardiac output slows blood flow. This causes hypotension and delayed capillary refill. Poor skin turgor is a sign of dehydration. Bounding peripheral pulses would be noted in a client with good cardiac output. 3+ lower extremity pitting edema is a sign of fluid volume overload.
The nurse is completing a teaching session for parents of a child who will be undergoing cardiac surgery to repair a birth defect. Which clinical manifestation should the nurse include when teaching the parents about an acid-base imbalance associated with postoperative pediatric cardiac surgery? (Select all that apply.) A. Dysrhythmias B. Irritability C. Seizures D. Decreasing level of consciousness (LOC) E. Cardiac arrest
A,C,D Rationale: Metabolic alkalosis is seen with a higher incidence in children who undergo cardiac surgery. Clinical manifestations of metabolic alkalosis include dysrhythmias, seizures, and decreasing LOC; thus, these should be included. Irritability and cardiac arrest are manifestations of respiratory acidosis.
The nurse is teaching a client with type 1 diabetes mellitus about disease management. What should the nurse include in the teaching plan to help the client prevent metabolic acidosis? (Select all that apply.) A. Take insulin as prescribed. B. Monitor blood glucose levels weekly. C. Notify healthcare provider when sick. D. Drink eight 8-ounce glasses of water per day. E. Consume diet soft drinks when nauseated or vomiting.
A,C,D Rationale: Many clients with type 1 diabetes mellitus believe if they are ill and unable to eat, they should not take their insulin. The nurse should instruct on the importance of taking insulin as prescribed and to notify their healthcare provider when sick. In order to maintain fluid volume and prevent imbalances, the diabetic client should take in eight 8-ounce glasses of water per day and even more when sick. Blood glucose levels should be checked more often than once a week, and diet soft drinks do not provide calories for the diabetic client when nauseated and vomiting.
The nurse is caring for a client who is experiencing an acid-base imbalance. Which category of care most accurately reflects considerations that are specifically related to client needs for the individual who is experiencing an acid-base imbalance? (Select all that apply.) A. Promoting oxygenation B. Preventing thermal injury C. Maintaining airway patency D. Restoring acid-base balance E. Facilitating effective breathing patterns
A,C,D ,E Rationale: For the client with an acid-base imbalance, nursing interventions are aimed at maintaining airway patency, promoting oxygenation, facilitating effective breathing patterns, preventing injury, promoting fluid volume balance, and restoring acid-base balance. An acid-base imbalance does not specifically predispose the client to a thermal injury.
The nurse is assessing a client for metabolic acidosis. Which manifestation is the nurse likely to observe? (Select all that apply.) A. Bradycardia B. Hypokalemia C. Skeletal problems D. Warm, flushed skin E. Nausea and vomiting
A,C,D, Rationale: Metabolic acidosis affects the function of several body systems. Symptoms of metabolic acidosis include bradycardia; warm, flushed skin; nausea and vomiting; and musculoskeletal problems. The client would not exhibit hypokalemia but hyperkalemia, as potassium is retained as the kidneys excrete excess hydrogen ions.
What action supports the nurse's plan of care for treating impaired gas exchange in the client with metabolic alkalosis? (Select all that apply.) A. Assess skin color. B. Assess intake and output. C. Monitor respiratory rate, depth, and effort. D. Place the client in Fowler or semi-Fowler position. E. Monitor mental status and level of consciousness.
A,C,D,E
Which is an appropriate nursing outcome for a client with metabolic alkalosis? (Select all that apply.) A. Oxygen saturation is 93% or greater. B. Muscle weakness is identified and treated. C. Normal acid-base balance is restored and maintained. D. The underlying cause of metabolic alkalosis is identified and treated. E. Normal or near normal fluid and electrolyte volumes are restored and maintained.
A,C,D,E Rationale: Appropriate nursing outcomes for a client with metabolic alkalosis include the following: Normal acid-base balance is restored and maintained; underlying cause of metabolic alkalosis is identified and treated; normal or near normal fluid and electrolyte volumes are restored and maintained; and oxygen saturation is 93% or greater. Muscle weakness is not a symptom of metabolic alkalosis, so the nurse would not anticipate this as a goal for the client with metabolic alkalosis.
The nurse is assessing the client for conditions that may increase the client's risk for developing specific acid-base imbalances. Which condition is most appropriate for the nurse to identify as a risk factor that may lead to the client's development of metabolic acidosis? (Select all that apply.) A. Severe diarrhea B. Hyperventilation C. Chronic renal failure D. High-dose salicylate ingestion E. Insulin-dependent diabetes mellitusA
A,C,D,E Rationale: Risk factors for the development of metabolic acidosis include insulin-dependent diabetes mellitus, chronic renal failure, severe diarrhea, and high-dose salicylate ingestion as these lead to bicarbonate loss. Hyperventilation is a risk factor for developing respiratory alkalosis due to loss of carbon dioxide because of rapid breathing.
The clinical nursing instructor is explaining how a decreased hydrogen ion concentration (H+) in the blood can trigger a compensatory response by the respiratory system. Which information is most appropriate for the clinical nursing instructor to include in the explanation? (Select all that apply.) A. The rate of respirations decreases. B. The depth of respirations increases. C. The body retains CO2 and water. D. The brain's respiratory center is stimulated. E. The blood concentration of carbonic acid increases.
A,C,E Rationale: A decrease in hydrogen ion concentration (H+) causes inhibition of the respiratory center in the brain, leading to a decrease in rate and depth of respiration (hypoventilation). The end result is the promotion of CO2 and water retention, which increases the concentration of carbonic acid and hydrogen ions (H+) in the blood.
Which intervention should the nurse implement to monitor for fluid volume deficit in the client with metabolic alkalosis? (Select all that apply.) A. Monitor serum electrolytes, osmolality, and ABG values. B. Assess skin color; note and report cyanosis around the mouth. C. Assess intake and output accurately, monitoring fluid balance. D. Assess vital signs, CVP, and peripheral pulse volume once per shift. E. Weigh daily under standard conditions (time of day, clothing, and scale).
A,C,E Rationale: To monitor for fluid volume deficit, the nurse should monitor serum electrolytes, osmolality, and ABG values; assess intake and output accurately to monitor for fluid balance; and weigh the client daily under standard conditions. Assessment of skin color for cyanosis around the mouth helps to monitor for impaired gas exchange, not fluid volume deficit. Vital signs, CVP, and peripheral pulse volume to monitor for fluid volume deficit should be done every four hours, not just once a shift.
Which nursing intervention would be most important for the nurse to implement in a client with confusion and mental status changes related to metabolic acidosis? A. Have familiar objects close. B. Keep a calendar in the room. C. Reorient the client frequently. D. Turn on the bed alarm.
B Rationale: Client safety is the most important intervention. If the client is confused, the nurse should turn on the bed alarm to alert the nurse if the client tries to get out of bed. Having familiar objects close, keeping a calendar in the room, and frequently reorienting the client will help decrease confusion, but these actions do not maintain safety.
Which preventable factor can cause metabolic acidosis in the older adult? A. Type 1 diabetes mellitus B. Salicylate poisoning C. Cardiac arrest D. Vomiting and diarrhea
B Rationale: Older adults may overuse salicylates in the treatment of arthritic pain. Salicylate poisoning is a cause of metabolic acidosis that can be prevented by taking the medication only as prescribed. Cardiac arrest, vomiting and diarrhea, and type 1 diabetes mellitus are not preventable causes of metabolic acidosis.
The nurse is administering sodium bicarbonate to a client with severe metabolic acidosis. As the pH begins to normalize, which laboratory value is most important to assess? A. Bicarbonate B. Potassium C. Creatinine D. Sodium
B Rationale: As the pH begins to normalize, potassium begins to shift back into the cell, leading to severe hypokalemia. This can cause life-threatening cardiac dysrhythmias. Sodium and bicarbonate should be monitored, but they are not the most important. Serum creatinine is not as important as potassium.
The clinical nurse educator is explaining the primary concepts of metabolic acidosis. Which statement is most appropriate for inclusion in the discussion about metabolic acidosis? A. Metabolic acidosis is associated with a deficit of carbonic acid (H2CO3). B. Bicarbonate (HCO3) deficit may lead to the development of metabolic acidosis. C. Bicarbonate (HCO3) excess may lead to the development of metabolic acidosis. D. Metabolic acidosis is associated with an excess of carbonic acid (H2CO3).
B Rationale: Bicarbonate (HCO3) deficit may lead to the development of metabolic acidosis. An excess of bicarbonate (HCO3) may lead to the development of metabolic alkalosis. Respiratory acidosis is associated with carbonic acid (H2CO3) excess, while respiratory alkalosis is associated with a deficit of carbonic acid (H2CO3).
The nurse is caring for a client who is receiving massive blood transfusions secondary to hypovolemic shock. Which rationale supports assessing this client for metabolic alkalosis? A. Hypovolemic shock increases the serum pH. B. Citrate toxicity decreases serum ionized calcium. C. Excessive blood transfusions cause hypokalemia. D. Heparin found in blood products decreases serum potassium.
B Rationale: Citrate is a preservative found in blood products. Citrate toxicity decreases serum ionized calcium, leading to metabolic alkalosis. Hypovolemic shock generally causes a decrease in the serum pH. Excessive blood transfusions are more likely to cause an allergic reaction not cause hypokalemia. Heparin found in blood products affects the coagulation of the blood and does not affect serum potassium.
The nurse is teaching a client about a new prescription of oral sodium bicarbonate. Which teaching point should be included? A. Use sodium antacids to relieve heartburn. B. Contact the healthcare provider with diaphoresis or chest pain. C. The goal of therapy is to relieve an acid-base imbalance. D. Do not use for longer than 1 month.
B Rationale: The client should be advised to contact the healthcare provider with continued stomach discomfort, diaphoresis, or chest pain. The sodium bicarbonate should not be used for more than 2 weeks without checking in with the healthcare provider again. The client should be advised to use no sodium antacids to prevent absorption of excess sodium or bicarbonate into the circulation. The goal of oral sodium bicarbonate is to neutralize stomach acid. Intravenous sodium bicarbonate is used to treat an acid-base imbalance.
The nurse is interpreting the following ABG analysis of a client who has taken an aspirin overdose: pH 7.21, pCO2 32 mmHg, HCO3 12 mEq/L, and pO2 88 mmHg. Which action is a priority for the nurse to perform? A. Observe for compensation. B. Look at the pCO2. C. Analyze the pH. D. Determine the bicarbonate level.
B Rationale: The nurse interprets acid-base status in an organized fashion, beginning with the interpretation of the pH. The second step in interpreting acid-base status is to assess the respiratory component, or pCO2. The third step in interpreting acid-base status is to assess the metabolic component, or the bicarbonate level. The nurse assesses for compensation after completing the assessments for pH, pCO2, and bicarbonate levels.
The nurse is caring for a 4-month-old male client who is experiencing an acid-base imbalance. Which nursing action should the nurse take next? A. Measure daily weights. B. Maintain airway patency. C. Monitor oxygen saturation. D. Record urine output.
B Rationale: Nursing interventions that may be appropriate for inclusion in the plan of care for the client who is experiencing an acid-base imbalance include maintaining airway patency, measuring daily weights, monitoring oxygen saturation, and recording urine output. Maintaining the client's airway patency, which is a safety measure, takes priority over the other nursing interventions.
The nurse is caring for a client admitted to a medical-surgical unit after a car crash. The client received several units of packed red blood cells while in surgery. The nurse begins to monitor this client for metabolic alkalosis due to receiving blood transfusions. Which other item in the client's health history would place this client at an increased risk for developing metabolic alkalosis? A. History of breast cancer B. History of low potassium C. History of depression D. History of two miscarriages
B Rationale: A history of hypokalemia, or low potassium, in addition to the numerous blood transfusions, would place this client at risk for metabolic alkalosis. Histories including two miscarriages, breast cancer, or depression do not place this client at a higher risk for developing metabolic alkalosis
The nurse is explaining the interpretation of arterial blood gas (ABG) results to a new graduate. Which principle is most appropriate for the nurse to include when explaining how to interpret ABG results? A. The normal PaCO2 level typically ranges from 45 to 55 mmHg. B. The normal PaO2 measurement usually is greater than 80 mmHg. C. Oxygen saturation normally ranges from 90% to 100% on room air. D. Normal bicarbonate level typically ranges between 28 and 38 mEq/L.
B Rationale: PaO2, which is a measurement of the partial pressure of oxygen in arterial blood, usually is greater than 80 mmHg. PaCO2, which is a measurement of the partial pressure of CO2 in arterial blood, normally ranges between 35 and 45 mmHg. Bicarbonate usually ranges between 24 and 28 mEq/L. SaO2, which is oxygen saturation, usually ranges between 95% and 100% on room air.
When a client with metabolic acidosis is placed on an electrocardiogram (ECG) monitor and the nurse sees peaked T waves or absent P waves with a widened QRS complex, which physiological condition is the client experiencing? A. Severe hyponatremia B. Severe hyperkalemia C. Severe hypernatremia D. Severe hypokalemia
B Rationale: Severe hyperkalemia manifests as peaked T waves with widened QRS complexes in an electrocardiogram (ECG). Hyperkalemia is present with acidosis. Hypokalemia is present with alkalosis. ECG waveform patterns do not indicate sodium levels.
What should the nurse educator include in a presentation regarding the causes of metabolic acidosis? (Select all that apply.) A. Self-induced vomiting B. Salicylate intoxication C. Uncontrolled diabetes mellitus D. Rapid infusion of sodium bicarbonate E. Chronic obstructive pulmonary disease (COPD)
B,C Rationale: Salicylate intoxication and uncontrolled diabetes mellitus are causes of metabolic acidosis. Self-induced vomiting and rapid infusion of sodium bicarbonate can lead to metabolic alkalosis. COPD can cause respiratory acidosis.
The nurse is providing care for a client with suspected metabolic alkalosis. Which clinical manifestation would support a diagnosis of metabolic alkalosis? (Select all that apply.) A. Headache B. Hypotension C. Seizures D. Tetany E. Hyperventilation
B,C,D Rationale: Hypotension, seizures, and tetany are all clinical manifestations of metabolic alkalosis. Additional clinical manifestations include confusion, decreasing level of consciousness (LOC), dysrhythmias, and respiratory failure. Headache and hyperventilation are clinical manifestations of metabolic acidosis.
The nurse preceptor is discussing the causes of metabolic acidosis with a new graduate. Which diagnosis would the preceptor include as a cause of metabolic acidosis? (Select all that apply.) A. Stroke B. Starvation C. Alcoholism D. Aspirin poisoning E. Excessive diarrhea
B,C,D,E Rationale: Metabolic acidosis is rarely a primary disorder. Starvation and alcoholism lead to ketoacidosis, which causes an increase in acid production and can cause metabolic acidosis. Aspirin poisoning also causes increased acid production, which can lead to metabolic acidosis. Diarrhea causes increased bicarbonate loss, which can lead to metabolic acidosis. A stroke might cause acute respiratory acidosis or respiratory alkalosis but not metabolic acidosis.
Which treatment modality would the nurse expect the healthcare provider to prescribe for a client admitted with alcoholic acidosis and a pH of 7.25? (Select all that apply.) A. Intravenous insulin B. Intravenous glucose C. Intravenous potassium D. Intravenous normal saline E. Intravenous sodium bicarbonate
B,D Rationale: Intravenous glucose and normal saline are administered to a client with alcoholic acidosis. Intravenous insulin and potassium are given for diabetic ketoacidosis. Intravenous sodium bicarbonate is administered if the pH is less than 7.10.
The long-term care nurse is teaching an orientation class concerning care of older adult clients to new assistive personnel. Which would the nurse include as important to ensure for the older adult clients to address a change in aging and to decrease the risk for development of metabolic alkalosis? A. Ensure high-protein shakes and supplements are offered frequently. B. Ensure that the older adult eats balanced meals. C. Ensure that the older adult has adequate fluid intake. D. Ensure that the older adult receives only small amounts of caffeinated fluids
C Rationale: Older adults have a diminished sense of thirst and can become volume depleted very quickly; thus, ensuring adequate fluid intake is important to help prevent the development of metabolic alkalosis. Ensuring balanced meals, limited caffeinated fluids, and frequent protein shakes/supplements neither address the change of age-related thirst nor directly affect the potential development of metabolic alkalosis.
The nurse knows sodium bicarbonate administration is contraindicated in which client? A. A 22-year-old man who is three days post-surgery for a fractured femur B. A 42-year-old female with a history of chronic heartburn C. A 72-year-old female with a history of renal failure D. A 45-year-old female with an elevated calcium level
C Rationale: Sodium bicarbonate should be used cautiously in clients with renal impairment or heart disease because of the sodium content. There is no contraindication in administering sodium bicarbonate to postsurgical or hypercalcemic clients. Sodium bicarbonate can be used to alleviate heartburn, so it is not contraindicated in that situation either.
The nurse is caring for a client with metabolic acidosis who presents with respiratory distress. Which laboratory value indicates a need to intubate and mechanically ventilate the client? A. Bicarbonate 25 mEq/L B. PaO2 greater than 60 mmHg C. PaCO2 greater than 77 mmHg D. pH greater than 7.10
C Rationale: A client with metabolic acidosis in respiratory distress would require intubation with mechanical ventilation if the PaCO2 is greater than 77 mmHg. A pH greater than 7.10 would not require intubation. The normal bicarbonate level is 21-26 mEq/L, so the client has a normal level. If the PaO2 is less than 60 mmHg, mechanical ventilation and intubation are required.
Which client being monitored for the potential development of metabolic alkalosis is the highest priority? A. A client with a sodium chloride intravenous solution B. A client experiencing ketoacidosis C. A client with continuous gastric suctioning D. A client with excessive diarrhea
C Rationale: Continuous gastric suction results in acid loss/excretion, thus contributing to the potential development of metabolic alkalosis. The nurse should carefully monitor this client for metabolic alkalosis. Excessive diarrhea, ketoacidosis, and sodium chloride intravenous solutions can all contribute to the potential development of metabolic acidosis.
Which factor places an infant with diarrhea at risk for metabolic acidosis? A. Potassium loss B. Calcium depletion C. Bicarbonate loss D. Sodium excess
C Rationale: Infants have a larger fluid volume than adults. When they develop diarrhea, this causes large amounts of bicarbonate loss, which causes metabolic acidosis. Sodium, potassium, and calcium changes do not lead to metabolic acidosis.
The nurse is teaching the parents of an infant with pyloric stenosis about potential acid-base imbalances that may occur. Which acid-base imbalance is most likely for the infant with pyloric stenosis? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis
C Rationale: Infants with pyloric stenosis have prolonged vomiting, which can cause metabolic alkalosis due to the loss of hypochloric acid. The nurse should teach the parents the signs and symptoms of metabolic alkalosis.
Which assessment finding indicates the possibility of renal failure in a client with metabolic acidosis? A. Bilateral adventitious lung sounds B. Bradycardia and dysrhythmias C. 24-hour urine output of 600 mL D. Dysuria and hematuria
C Rationale: Urine output should be 30 mL/hour. When cardiac output decreases in metabolic acidosis, this can affect renal perfusion. A 24-hour urinary output of 600 mL indicates only 25 mL/h. This decreased renal perfusion can cause renal failure. Dysuria and hematuria can indicate a urinary tract infection. Bradycardia can happen from decreased cardiac output; dysrhythmias from hyperkalemia. Bilateral adventitious lung sounds can indicate fluid overload.
The nurse caring for a pediatric client receives a handoff report and learns the child has just had an arterial blood gas (ABG) drawn. The lab calls to report the serum pH is 7.0. Which conclusion by the nurse is the most appropriate? A. The result indicates alkalosis and needs immediate attention. B. The result is normal and no action is necessary at this time. C. This result indicates acidosis and requires immediate attention. D.
C Rationale: A serum pH below 7.35 indicates acidosis, a condition with an excess of hydrogen ions or loss of base ions (bicarbonate) in the extracellular fluid. The client needs immediate attention; waiting and drawing labs again in an hour is not appropriate. A serum pH above 7.45 indicates alkalosis, a condition with a lack of hydrogen ions or a gain of base ions (bicarbonate). Death will occur if the pH rises above 7.80. Next Question
A nurse is caring for several clients with acid-base imbalances. Which client will likely require intubation and mechanical ventilation? A. A client with a pH of 7.25 B. A client with oxygen saturation of 94% C. A client with a PaO2 of 79 mmHg D. A client with a PaCO2 of 82 mmHg
D Rationale: Monitoring airway patency and respiratory effort are important interventions for the client with an acid-base imbalance. Intubation and mechanical ventilation are generally indicated when PaCO2 is greater than 77 mmHg, pH is less than 7.2, or PaO2 is less than 60 mmHg.
The nurse is caring for four clients today. Which client would the nurse expect to be at highest risk for metabolic acidosis? A. 80-year-old with chronic obstructive pulmonary disease B. 50-year-old with pneumonia C. 60-year-old with deep vein thrombosis D. 70-year-old with chronic kidney disease
D Rationale: Older adults have decreased renal function, and a 70-year-old with chronic kidney disease would be at the highest risk due to the inability to excrete hydrogen ions in the urine. A client with pneumonia and chronic obstructive pulmonary disease would have respiratory acidosis or alkalosis. Deep vein thrombosis does not cause metabolic acidosis.
Which assessment data should the nurse use to most accurately determine fluid balance for the client with metabolic alkalosis? A. Excess intake balance of 500 mL for the most recent 12-hour shift B. Decrease in client systolic blood pressure of 20 mmHg since last reading C. Lab values indicating hypokalemia D. Client weight gain of 2.4 lb in the past 24 hours
D Rationale: Clients with metabolic alkalosis often have accompanying fluid volume deficit. The most accurate reflection of fluid balance is rapid weight changes. Thus the weight gain of 2.4 lb in the past 24 hours would be the most accurate indicator of fluid balance. Lab values, intake and output, and blood pressure can also reflect fluid balance changes but are not the most accurate indicators of fluid balance.
Which collaborative care goal is most appropriate for the nurse to include in the plan of care for a client with metabolic acidosis secondary to influenza? A. The client will maintain the head of the bed in a high-Fowler position. B. The client will have an oral fluid intake of 2000 mL in 24 hours. C. The client will reach 1500 mL on incentive spirometer. D. The client will have serum electrolytes within normal limits.
D Rationale: Collaborative care goals are those that require orders from the healthcare provider or other disciplines to meet. Serum electrolyte status requires an order to implement. Oral fluid intake, incentive spirometer, and elevating the head of the bed are set by the nurse and are met by independent nursing interventions.
Which condition or laboratory data indicates an adverse effect when administering sodium bicarbonate for treatment of metabolic acidosis? A. Hyperkalemia B. Hyponatremia C. pH of 7.30 D. Hyperosmolalit
D Rationale: Rapid correction of metabolic acidosis with sodium bicarbonate may lead to hypernatremia, not hyponatremia, which causes water retention and fluid overload. Rapid correction of metabolic acidosis with sodium bicarbonate may lead to metabolic alkalosis and hypokalemia, not hyperkalemia. Rapid correction of metabolic acidosis with sodium bicarbonate may lead to hyperosmolality, which can lead to water retention and fluid overload. Therefore, it is essential to administer sodium bicarbonate only for severe metabolic acidosis and to closely monitor the client. Rapid correction of metabolic acidosis with sodium bicarbonate may lead to metabolic alkalosis and a pH greater than 7.45. A pH of 7.30 indicates metabolic acidosis and that the client did not have an adverse reaction to the sodium bicarbonate.
During a review of medications for an 83-year-old client, the nurse finds that the client has been frequently using sodium bicarbonate for heartburn. What action should the nurse take in response to this information? A. Immediately obtain diagnostic studies to ensure that metabolic alkalosis is not occurring. B. Alert the client to possible side effects related to the use of sodium bicarbonate C. Inform the client that it is acceptable to use this antacid if fluid intake is adequate. D. Advise the client to use other antacid preparations without sodium bicarbonate.
D Rationale: Use of sodium bicarbonate antacids can predispose clients to metabolic alkalosis. The nurse should advise the client to use a different antacid preparation. Alerting the client to possible side effects would not decrease the potential for metabolic alkalosis. Adequate fluid intake does not offset the risk of metabolic alkalosis with sodium bicarbonate use. There is no information in the scenario that would indicate the need for immediate diagnostic studies.
The nurse is evaluating arterial blood gas results on a client admitted with pulmonary disease. The pH is 7.19. Which nursing action is most appropriate? A. Reassess the client in 2 hours. B. Lower the head of the bed. C. Instruct the client to take slow, deep breaths. D. Notify the healthcare provider.
D Rationale: A pH of 7.19 indicates acidosis, which requires immediate notification of the healthcare provider so that treatment can begin. The client should be treated immediately and be continually assessed. A supine position will not assist a client with a pH of 7.19. Elevating the head of the bed will assist with respiratory function. Slow breathing is not the appropriate nursing action for a client with a pH of 7.19. The client is in acidosis and needs to get rid of acid by rapid breathing.
The nurse is reviewing the physiology of acid-base balance. Which body organ is involved in regulating acid-base balance? A. Skin B. Heart C. Hypothalamus D. Kidneys
D Rationale: The kidneys excrete and retain hydrogen ions. They also form and excrete bicarbonate ions in response to the blood's pH level because the concentration of bicarbonate in the plasma is regulated by the kidney. The kidneys and the lungs are the organs that work to maintain the acid-base balance. The heart can be detrimentally affected by an imbalance (heart failure, arrhythmias) but does not directly affect homeostasis of the acid-base system. The hypothalamus functions as the trigger for the thirst mechanism for the maintenance of fluids and electrolytes. The skin serves as a source of some fluid loss but does not serve to regulate the body's acid-base.
The nurse is caring for a client who is experiencing an acid-base imbalance. When considering the physiologic processes that are involved in correcting acid-base imbalances, which primary mechanism of compensation is most appropriate for the nurse to anticipate being first to respond? A. The renal system B. The cardiovascular system C. The respiratory system D. The buffer systems
D Rationale: The primary mechanisms of compensation include the buffer systems, which may be activated within seconds of developing an acid-base imbalance; the respiratory system, which may be activated within minutes of developing an acid-base imbalance; and the renal system, which may take hours or days to activate in response to developing an acid-base imbalance. The cardiovascular system is not a primary mechanism of compensation for acid-base imbalance.
The nurse preceptor asks a new graduate to explain acid-base balance. Which statement is accurate? A. The range for normal blood pH varies greatly depending on cultural and racial heritage. B. A blood pH of 7.32 is reflective of alkalosis. C. A blood pH of 7.54 is reflective of acidosis. D. Maintenance of normal blood pH requires the presence of more bicarbonate than carbonic acid.
D Rationale: Maintenance of blood pH within a range of 7.35 to 7.45 requires a ratio of 1 part carbonic acid (H2CO3) to 20 parts bicarbonate (HCO3). The normal pH of extracellular body fluids—including blood—is 7.35 to 7.45. A blood pH of less than 7.35 is reflective of acidosis, while a blood pH of greater than 7.45 is reflective of alkalosis. Cultural and racial heritage do not affect the range of normal blood pH.
The nurse is caring for a client with an acid-base imbalance secondary to prolonged vomiting. Which acid-base imbalance should the nurse monitor? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Metabolic acidosis
Metabolic alkalosis Rationale: Clients with prolonged vomiting are at higher risk for developing metabolic alkalosis. High amounts of stomach acid are lost with vomiting, leading to excess bicarbonate. Prolonged vomiting does not lead to metabolic acidosis, respiratory acidosis, or respiratory alkalosis.
A nurse is caring for a client who is diagnosed with metabolic alkalosis. Which should the nurse include in the assessment of this client? (Select all that apply.) A. Oxygen saturation B. ABG interpretation C. Deep tendon reflexes D. Presence of muscle weakness E. Presence of numbness and tingling
a,b,c,e Rationale: When assessing a client with metabolic alkalosis, the nurse will include ABG interpretation, deep tendon reflexes, oxygen saturation, and presence of numbness and tingling. The nurse would assess for the presence of muscle spasm, not weakness, for this client.
The healthcare provider orders the administration of two IV boluses of sodium bicarbonate, 44 mEq for a client with metabolic acidosis. For which common adverse effect should the nurse monitor this client during the administration of sodium bicarbonate? A. Generalized hives B. Vomiting C. Diarrhea D. Hypercapnia
b Rationale: Adverse reactions associated with the administration of sodium bicarbonate include confusion, irritability, decreased respiratory rate, and vomiting. Although hypercapnia may be associated with a severely-depressed respiratory rate, it is not an adverse effect associated with the administration of sodium bicarbonate. Neither diarrhea nor hives is associated with sodium bicarbonate administration.
The nurse is caring for a client diagnosed with metabolic alkalosis. Which intervention should the nurse include when establishing the plan of care? A. Monitor for pain. B. Administer antiemetics as prescribed. C. Encourage slow, deep respirations. D. Promote early ambulation.
b Rationale: One cause of metabolic alkalosis is vomiting. Antiemetics can help prevent this from occurring. Acute pain that might require medication is seen with respiratory, not metabolic, alkalosis. Encouraging slow, deep respirations would be indicated for a client with respiratory alkalosis. Early ambulation is encouraged with respiratory acidosis, not with metabolic alkalosis.
The nurse is caring for a client with respiratory acidosis. Which healthcare provider order should the nurse question? A. Monitor strict fluid intake and output. B. Administer postural drainage and percussion every 8 hours. C. Administer sodium bicarbonate intravenously. D. Assess vital signs every 2 hours.
c Rationale: The nurse should question an order for administration of sodium bicarbonate. Intravenous sodium bicarbonate is indicated with metabolic acidosis, not respiratory acidosis. A client with respiratory acidosis requires frequent assessment of vitals, intake/output, ABGs, and airway. The client should maintain a fluid intake of at least 2 to 3 liters per day. Pulmonary therapy, such as inhalation, percussion, and postural drainage are also indicated
The nurse walks into the client's room to administer medications for a client with an acid-base balance and notes that the client is pacing anxiously. How should the nurse proceed? A. Administer morning medications as planned. B. Walk out of the room quietly to provide privacy. C. Speak with the client in a soft and calm voice. D. Inform the healthcare provider.
c Rationale: Anxiety and stress are common responses to illness and hospitalization. Nursing interventions for this client include providing reassurance, using distraction and speaking in a slow, calm voice. The nurse should not leave the client alone or administer the medications without acknowledging how the client feels. The nurse should work with the client to minimize stress and anxiety before contacting the healthcare provider.
