Week 13: Acid-Base Imbalance; Analyze Cues and Prioritize Hypotheses; Plan and Generate Solutions

The nurse is caring for a patient with dyspnea and impaired gas exchange secondary to chest injury causing respiratory acidosis. Which evaluation would the nurse include in the plan of care to specifically monitor a goal of returning blood pressure to baseline or within normal limits (WNL) within 24 hours of admission? Hydration Vital signs Fluid balance Respiratory status

HydrationEvaluating hydration relates indirectly to blood pressure, but it would not provide information specific to the goal of returning blood pressure to baseline or WNL within 24 hours of admission. Correct Vital signsVital signs would provide blood pressure readings to confirm that the goal has been reached. Fluid balanceFluid balance relates indirectly to blood pressure, but it would not provide information specific to the goal of returning blood pressure to baseline or WNL within 24 hours of admission. Respiratory statusRespiratory status would not provide information specific to the goal of returning blood pressure to baseline or WNL within 24 hours of admission.

Match each hypothesis with the acid-base imbalance. 1-Impaired Gas Exchange 2-Hyperventilation 3-Excess acid production 4-Excess serum bicarbonate A-Respiratory acidosis B-Respiratory alkalosis C-Metabolic alkalosis D-Metabolic acidosis

1-A 2-B 3-D 4-C

Which conditions in the medical history would the nurse identify as a risk factor for metabolic acidosis? Select all that apply. Asthma Hypertension Type I diabetes Sepsis Vomiting

AsthmaAsthma places the patient at risk for respiratory, not metabolic, acidosis. HypertensionHypertension is not an underlying factor of acid-base imbalance. Correct Type I diabetesType I diabetes can cause ketoacidosis, which leads to acid accumulation and metabolic acidosis. Correct SepsisIn sepsis, lack of oxygen available to the cells results in anaerobic metabolism and the accumulation of lactic acid. VomitingVomiting results in loss of stomach acid, which places the patient at risk for alkalosis, not acidosis.

Which data in the medical history of a patient who is awake, but lethargic, and taking rapid, deep breaths would the nurse suspect as the cause of the following laboratory values: pH 7.31, PaO2 59.2 mm Hg, PaCO2 38.6 mm Hg, HCO3- 17.5 mEq/L, and oxygen saturation 88%? Asthma Antacid use Diabetes mellitus Diuretic use

AsthmaThese data are not indicative of asthma. Asthma can cause respiratory acidosis. Antacid useThese data are not indicative of antacid use. Antacids would be associated with metabolic alkalosis. Correct Diabetes mellitusThe pH and HCO3- values indicate metabolic acidosis, and the Kussmaul respirations are consistent with diabetic ketoacidosis. Diuretic useThese data are not indicative of diuretic use. Diuretics can cause metabolic alkalosis.

Which change in respiratory pattern observed in a type I diabetic patient with metabolic acidosis indicates to the nurse that compensation is occurring? Bradypnea Tachypnea Kussmaul respirations Cheyne-Stokes respirations

BradypneaBradypnea (regular, slow respirations) typically indicates that the patient is asleep. This does not indicate compensation. TachypneaTachypnea is rapid, short breathing. This does not indicate compensation. Correct Kussmaul respirationsKussmaul respirations remove excess carbon dioxide from the system. This is an indication of compensation. Cheyne-Stokes respirationsCheyne-Stokes respirations, or periodic breathing, are present at the end of life. This does not indicate compensation.

Which patients would the nurse identify as being at risk for respiratory acidosis secondary to impaired gas exchange? Select all that apply. A patient experiencing an asthma attack A patient diagnosed with Guillain-Barré syndrome A patient who is 2 hours postoperative for thoracic surgery A patient with a fear of being hospitalized A patient with a nicotine overdose

Correct A patient experiencing an asthma attackAsthma constricts the airways and decreases exhalation, placing the patient at risk for respiratory acidosis secondary to impaired gas exchange. Correct A patient diagnosed with Guillain-Barré syndromeNeurologic disorders such as myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis affect the muscles of respiration, placing the patient at risk for respiratory acidosis secondary to impaired gas exchange. Correct A patient who is 2 hours postoperative for thoracic surgeryChest trauma/surgery impairs ventilation, placing the patient at risk for respiratory acidosis secondary to impaired gas exchange. A patient with a fear of being hospitalizedFear causes hyperventilation and increases the risk for respiratory alkalosis, not acidosis. A patient with a nicotine overdoseNicotine overdose leads to hyperventilation and increases the risk for respiratory alkalosis, not acidosis.

Which solutions are appropriate for a nurse to include in the plan of care for a diabetic patient with metabolic acidosis? Select all that apply. Decrease blood sugar Return to normal vital signs Replace fluid loss Improve memory Correct electrolyte imbalances

Correct Decrease blood sugarDecreased blood sugar is an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. These patients present with elevated blood glucose levels. Return to normal vital signsVital signs is not a specific outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. Correct Replace fluid lossReplacing fluid loss is an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. These patients often have a fluid deficit of as much as 6 L in severe cases. Improve memoryMemory is not an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. Correct Correct electrolyte imbalancesCorrecting electrolyte imbalances is an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. These patients often have potassium imbalances.

Which actions would the nurse perform when analyzing ABG values for a patient suspected of having an acid-base imbalance? Select all that apply. Examining oxygenation status Evaluating the pH Assessing PaCO2 and HCO3- Monitoring potassium Determining compensation

Correct Examining oxygenation statusThe first step the nurse performs when analyzing ABG values is to examine the oxygenation status to determine if the patient is experiencing hypoxemia. Correct Evaluating the pHThe second step the nurse performs when analyzing ABG values is to evaluate the pH to determine if the patient is acidotic or alkalotic. Correct Assessing PaCO2 and HCO3-The third step the nurse performs when analyzing ABG values is to assess PaCO2 and HCO3- values. This allows the nurse to determine whether the underlying issue is metabolic or respiratory in nature. Monitoring potassiumPotassium level is not a criterion that is used to analyze ABG values. Correct Determining compensationThe final step the nurse performs when analyzing ABG values is to determine compensation.

Which ABG data would the nurse identify as supporting the diagnosis of metabolic alkalosis in a patient admitted with dehydration and lethargy? Select all that apply. Increased pH Decreased pH Increased bicarbonate Decreased bicarbonate Decreased PaO2

Correct Increased pHDehydration and lethargy coupled with an increased pH support the diagnosis of metabolic alkalosis. Decreased pHDecreased pH with the current data does not support the diagnosis of metabolic alkalosis. The decreased pH is consistent with acidosis. Correct Increased bicarbonateDehydration and lethargy coupled with an increased bicarbonate level support the diagnosis of metabolic alkalosis. Decreased bicarbonateDecreased bicarbonate with the current data does not support the diagnosis of metabolic alkalosis. Metabolic alkalosis would be associated with increased bicarbonate. Decreased PaO2Decreased PaO2 may be associated with respiratory acidosis, not metabolic acidosis.

Which acid-base imbalance would the nurse suspect in a patient presenting with muscle twitching and tetany who experiences a seizure 10 minutes after hospital admission? Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis

Correct Metabolic alkalosisClinical manifestations associated with metabolic alkalosis include muscle twitching and tetany that may progress to seizure. Metabolic acidosisMuscle twitching, tetany, and seizure are not clinical manifestations associated with metabolic acidosis. Respiratory alkalosisMuscle twitching, tetany, and seizure are not clinical manifestations associated with respiratory alkalosis. Respiratory acidosisMuscle twitching, tetany, and seizure are not clinical manifestations associated with respiratory acidosis.

Which additional cues would the nurse expect when caring for a patient with Acute Confusion associated with respiratory alkalosis? Select all that apply. Muscle cramping Restlessness Tachypnea Abdominal pain Paresthesia

Correct Muscle crampingHyperventilation can cause muscle cramping as a result of hypocalcemia. This respiratory alkalosis is also associated with tachypnea, lightheadedness, numbness and tingling of extremities, paresthesia, palpitations, cardiac dysrhythmias, anxiety, restlessness, and decreased level of consciousness. Correct RestlessnessHyperventilation can be associated with restlessness and is also associated with tachypnea, lightheadedness, numbness and tingling of extremities, paresthesia, muscle cramping, palpitations, cardiac dysrhythmias, anxiety, and decreased level of consciousness. Correct TachypneaAcute Confusion with respiratory alkalosis is associated with tachypnea or Hyperventilation. It is also associated with lightheadedness, numbness and tingling of extremities, paresthesia, muscle cramping, palpitations, cardiac dysrhythmias, anxiety, restlessness, and decreased level of consciousness. Abdominal painAbdominal pain may be found in a patient with excess acid production along with headache, weakness, nausea, anorexia, Kussmaul respirations, tachycardia, cardiac dysrhythmias, hypotension, decreased level of consciousness (confusion, lethargy, stupor, and coma), and vomiting. ParesthesiaParesthesia may be found in a patient with excess serum bicarbonate along with lightheadedness, bilateral muscle weakness, anorexia, nausea, lethargy, seizures, hypotension, hypoventilation, cardiac dysrhythmias, muscle twitching and tetany, increased deep tendon reflexes, vomiting, polyuria, mental confusion, and coma.

An older adult patient with a history of tobacco use reports fatigue, decreased energy, and difficulty breathing. The hypothesis includes Impaired Gas Exchange with respiratory acidosis. Which goal statement specific for fatigue would the nurse include in the plan of care? Patient will verbalize feelings of increased energy within 24 hours of admission. Patient will seek information about the plan of care at the time of admission. Patient will find time to nap between treatment sessions. Patient will quit smoking within 3 months.

Correct Patient will verbalize feelings of increased energy within 24 hours of admission.This goal is specific, measurable, and related to fatigue. Patient will seek information about the plan of care at the time of admission.This goal is not measurable and is not related to fatigue. This could be corrected by adding a time frame and a focus on fatigue. Patient will find time to nap between treatment sessions.While this goal is patient-centered, it is not specific or measurable. This could be corrected by adding the duration of naps and how many would take place in a fixed amount of time. Patient will quit smoking within 3 months.This goal is not measurable and is not related to fatigue.

Which conclusion would the nurse make when the ABG results for a patient suspected of having an acid-base imbalance reveal a decreased pH, increased PaCO2, and normal HCO3-? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Correct Respiratory acidosisA decreased pH, an increased PaCO2, and a normal HCO3- indicate that the patient is experiencing respiratory acidosis. Respiratory alkalosisA decreased pH, an increased PaCO2, and a normal HCO3- would not indicate respiratory alkalosis. Respiratory alkalosis would be associated with an increased pH, a decreased PaCO2, and a normal HCO3-. Metabolic acidosisA decreased pH, an increased PaCO2, and a normal HCO3- would not indicate metabolic acidosis. Metabolic acidosis would be associated with a decreased pH, a normal PaCO2, and a decreased HCO3-. Metabolic alkalosisA decreased pH, an increased PaCO2, and a normal HCO3- would not indicate metabolic alkalosis. Metabolic alkalosis would be associated with an increased pH, a normal PaCO2, and an increased HCO3-.

Which acid-base imbalance would the nurse anticipate in a patient after a motor vehicle accident in which the steering wheel hit the patient's chest and trapped the patient in the car until rescue workers arrived? Respiratory acidosis Chronic acidosis Respiratory alkalosis Compensatory alkalosis

Correct Respiratory acidosisTrauma to the chest decreases ventilation and impairs gas exchange, placing the patient at risk for respiratory acidosis. Chronic acidosisThis patient has an acute injury; therefore the patient is not at risk for chronic acidosis. Respiratory alkalosisThe patient is not hyperventilating, so this patient is not at risk for respiratory alkalosis. Compensatory alkalosisCompensatory mechanisms happen after the initial imbalance has occurred; therefore the patient is not at risk for compensatory alkalosis.

The nurse is caring for a patient who fell and is receiving treatment for a fractured arm. The nurse reviews the patient's laboratory results, which indicate an elevated pH and a decreased PaCO2. Which condition is the patient experiencing based on the current data? Respiratory alkalosis Metabolic acidosis Renal compensation Hypoxemia

Correct Respiratory alkalosisAn elevated pH value and a decreased PaCO2 value are consistent with respiratory alkalosis. Metabolic acidosisThis scenario is not indicative of metabolic acidosis because the pH is elevated and reflecting alkalosis. Renal compensationThe laboratory results do not indicate renal compensation. HypoxemiaThe laboratory results do not indicate hypoxemia. Hypoxemia would be indicated by a PaO2 less than 80 mm Hg.

Which cardiovascular findings would the nurse anticipate in a patient with respiratory acidosis? Select all that apply. Tachycardia Dysrhythmia Hypotension Dyspnea Confusion

Correct TachycardiaTachycardia is an expected cardiovascular assessment finding for a patient who is experiencing respiratory acidosis. Correct DysrhythmiaDysrhythmia is an expected cardiovascular assessment finding for a patient who is experiencing respiratory acidosis. HypotensionHypotension is not an expected cardiovascular assessment finding for a patient who is experiencing respiratory acidosis. Hypotension is associated with metabolic alkalosis. DyspneaDyspnea is a respiratory, not cardiovascular, assessment finding that is expected for a patient who is experiencing respiratory acidosis. Dyspnea a respiratory finding and is not associated with the cardiovascular system. ConfusionConfusion is a neurologic, not cardiovascular, assessment finding that is expected for a patient who is experiencing respiratory acidosis. Confusion is associated with metabolic acidosis.

Which clinical manifestation would the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis? Dyspnea Tachypnea Hypertension Hypotension

DyspneaDyspnea is a clinical manifestation the nurse would anticipate for a patient who is experiencing respiratory acidosis, not alkalosis. Correct TachypneaTachypnea is a clinical manifestation the nurse would anticipate for a patient who is experiencing respiratory alkalosis. HypertensionHypertension is not a clinical manifestation the nurse would anticipate for a patient who is experiencing respiratory alkalosis. HypotensionHypotension is not a clinical manifestation the nurse would anticipate for a patient who is experiencing respiratory alkalosis. Hypotension is associated with metabolic alkalosis.

Which assessment finding would cause the nurse to suspect that a patient is experiencing metabolic acidosis? Dyspnea Kussmaul respirations Polyuria Muscle twitching

DyspneaDyspnea is an assessment finding that would cause the nurse to suspect respiratory, not metabolic, acidosis. Correct Kussmaul respirationsKussmaul respirations are frequent, deep breaths that constitute a compensatory mechanism to exhale more carbon dioxide. This is an assessment finding that would cause the nurse to suspect that the patient is experiencing metabolic acidosis. PolyuriaPolyuria is an assessment finding that would cause the nurse to suspect metabolic alkalosis, not acidosis. Muscle twitchingMuscle twitching is an assessment finding that would cause the nurse to suspect metabolic alkalosis, not acidosis.

Which hypotheses would the nurse consider when handed over a patient with an acid-base imbalance who has Kussmaul respirations and is reported to be hypotensive and dysrhythmic? Impaired Gas Exchange Hyperventilation Excess acid production Excess serum bicarbonate

Impaired Gas ExchangeImpaired Gas Exchange is associated with dysrhythmias but not hypotension. HyperventilationHyperventilation is associated with dysrhythmias but not hypotension. It is also often associated with acute confusion. Correct Excess acid productionExcess acid production is associated with hypotension and dysrhythmias as well as Kussmaul respirations. Excess serum bicarbonateExcess serum bicarbonate is associated with hypotension and dysrhythmias but not Kussmaul respirations.

Which acid-base imbalance would the nurse suspect when providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3- 20 mEq/L? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosisThe nurse would not suspect respiratory acidosis based on these ABG values. Respiratory acidosis would be associated with a decreased pH, an increased PaCO2, and a normal HCO3-. Respiratory alkalosisThe nurse would not suspect respiratory alkalosis based on these ABG values. Respiratory alkalosis would be associated with an increased pH, a decreased PaCO2, and a normal HCO3-. Correct Metabolic acidosisMetabolic acidosis is characterized by a decreased pH, a normal PaCO2, and a decreased HCO3-. This is appropriate for the nurse to suspect based on the ABG analysis. Metabolic alkalosisThe nurse would not suspect metabolic alkalosis based on these ABG values. Metabolic alkalosis would be associated with an increased pH, a normal PaCO2, and an increased HCO3-.

Which assessments would the nurse perform in all patients experiencing an acid-base imbalance? Select all that apply. Skin turgor Urine output Bowel sounds ABG analysis Vital signs

Skin turgorSkin turgor is not an assessment parameter for all patients who are suspected of having an acid-base imbalance. Urine outputUrine output is not an assessment parameter for all patients who are suspected of having an acid-base imbalance. Bowel soundsAuscultating bowel sounds is not an assessment parameter for all patients who are suspected of having an acid-base imbalance. Correct ABG analysisAll patients who are suspected of having an acid-base imbalance will require an ABG analysis. Correct Vital signsAll patients who are suspected of having an acid-base imbalance will require a vital signs assessment.