Exam 4 Review
The nurse is caring for the client with a history of anxiety who is experiencing chest pain, palpitations, and dyspnea. Which intervention would be a priority for this client? A) Providing educational material for the client's medical diagnosis B) Ordering a regular diet for the client C) Reassuring the client that symptoms will resolve D) Asking Respiratory Therapy to set up a mechanical ventilator
C
The nurse identifies the diagnosis Risk for Impaired Gas Exchange to guide the care of a client with metabolic alkalosis. What did the nurse assess to support this diagnosis? Select all that apply. A) Respiratory rate 8 per minute B) Oxygen saturation 89% C) Urine output 25 mL/hr D) Restlessness and agitation E) Weight loss of 3 kg overnight
Answer: A, B, D A) Respiratory rate 8 per minute B) Oxygen saturation 89% D) Restlessness and agitation
The nurse is caring for the client experiencing hypovolemic shock and metabolic acidosis. Which of the following therapies would the nurse question if planned for this client? Select all that apply. A) Monitor weight on admission and discharge. B) Monitor ECG for conduction problems. C) Limit the intake of fluids. D) Administer sodium bicarbonate. E) Keep the bed in the locked and low position.
Answer: A, C A) Monitor weight on admission and discharge. C) Limit the intake of fluids.
During an assessment, the nurse becomes concerned that a client is at risk for developing metabolic alkalosis. What did the nurse assess that caused this concern? A) Daily ingestion of a banana with breakfast B) Daily weight consistent C) Daily use of sodium bicarbonate for gastric upset D) Daily use of prescribed NSAIDs for arthritic pain
Answer: C C) Daily use of sodium bicarbonate for gastric upset
9) The nurse is preparing to analyze a client's arterial blood gas results. List the steps in the order that the nurse should follow when analyzing this laboratory test. 1. Look at the PaCO2. 2. Look at the pH. 3. Evaluate the relationship between pH and PaCO2. 4. Look for compensation. 5. Evaluate the pH, HCO3, and base excess for a possible metabolic problem. 6. Look at the bicarbonate. 7. Evaluate oxygenation.
2, 1, 3, 6, 5, 4, 7
9) The nurse is preparing to instruct a client with type 1 diabetes mellitus on the mechanism behind the development of ketoacidosis. List the order in which the nurse should provide this information. 1. Production of lactate and hydrogen ions 2. Development of lactic acidosis 3. Breakdown of fatty tissue 4. Reduction in intracellular glucose 5. Fatty acids converted to ketones
2, 1, 4, 3, 5
A client with injuries from a motor vehicle crash is intubated for respiratory support. The nurse notes that the client is fighting the ventilator and attempting to pull out the endotracheal tube. What should the nurse do to reduce this client's risk of developing respiratory alkalosis? A) Administer a sedative as prescribed. B) Apply wrist restraints. C) Teach the client to take slow, deep breaths. D) Discuss removing the endotracheal tube with the healthcare provider.
A
The nurse has completed discharge teaching for a client with an anxiety disorder. Which client statement indicates that client teaching about respiratory alkalosis has been effective? A) "I will see my counselor on a regular basis." B) "I will breathe faster when I am feeling anxious." C) "I will eat more bananas at breakfast." D) "I will not take antacids when I have heartburn."
A
The nurse is planning care for a client who has been admitted to the unit with a salicylate overdose. When preparing the plan of care, the nurse considers which to be a priority nursing diagnosis? A) Ineffective Breathing Pattern B) Powerlessness C) Risk for Injury D) Impaired Mobility
A
A client is admitted to the hospital with sudden, severe abdominal pain. The client is diagnosed with respiratory alkalosis. Which arterial blood gas value does the nurse document to support this diagnosis? A) pH is 7.33 and PaCO2 is 36. B) pH is 7.51 and HCO3 is 30. C) pH is 7.47 and PaCO2 is 25. D) pH is 7.35 and PaO2 is 88.
C
The nurse is analyzing the client's arterial blood gas report, which reveals a pH of 6.58. The client has just suffered a cardiac arrest. Which of the following consequences does the nurse consider for this client? A) Decreased cardiac output B) Increase magnesium levels C) Decreased free calcium in the ECT D) Increased myocardial contractility
A) Decreased cardiac output
The nurse is evaluating care provided to a client with respiratory alkalosis. Which outcomes indicate that nursing care has been effective for this client? Select all that apply. A) Respiratory rate 18 and regular B) Sleeping through the night C) Gait steady D) Consistent body weight E) Using prescribed bronchodilators
ABCD
The client with an anxiety disorder is ready to be discharged from the unit. What should the nurse plan to teach this client and family in preparation for discharge? Select all that apply. A) Refer the client for counseling. B) Instruct the client to eat foods high in acid. C) Teach the client the signs of impending panic attack. D) Advise the client to breathe into a paper bag when feeling anxious. E) Instruct the client to breathe slowly.
ACE
The nurse is preparing to instruct a client with type 1 diabetes mellitus on the mechanism behind the development of ketoacidosis. List the order in which the nurse should provide this information. 1. Production of lactate and hydrogen ions 2. Development of lactic acidosis 3. Breakdown of fatty tissue 4. Reduction in intracellular glucose 5. Fatty acids converted to ketones
Answer: 2, 1, 4, 3, 5
The nurse is caring for a client admitted with renal failure and metabolic acidosis. Which of the following signs would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective? A) Decreased respiratory depth B) Palpitations C) Increased deep tendon reflexes D) Respiratory rate of 38
Answer: A A) Decreased respiratory depth
A client with hyperaldosteronism has been admitted to the unit. The nurse knows the client is at risk for impaired gas exchange. Which position should this client be placed to enhance gas exchange? A) Fowler's position B) Prone position C) Left side-lying position D) Right Sims position
Answer: A A) Fowler's position
A school-age client is admitted to the hospital with respiratory acidosis. Which chronic lung illness in the client's health history does the nurse suspect is causing the current diagnosis? A) Cystic fibrosis B) Aspiration C) Hyperthyroidism D) Pneumonia
Answer: A Explanation: A) Chronic lung disease such as asthma and cystic fibrosis put the child at risk for respiratory acidosis. Pneumonia and aspiration are both acute lung conditions. Hyperthyroidism is a disorder that results in metabolic acidosis.
A client is admitted to the unit with chronic obstructive pulmonary disease. Blood gas analysis indicates respiratory acidosis. Based on this data, the nurse plans care based on which priority diagnosis? A) Impaired Gas Exchange B) Ineffective Airway Clearance C) Impaired Mobility D) Anxiety
Answer: A Explanation: A) Impaired Gas Exchange is the priority nursing diagnosis for the client with respiratory acidosis. Interventions are aimed at restoring effective alveolar ventilation and gas exchange. Anxiety and Ineffective Airway Clearance are both appropriate nursing diagnoses but not priority for the client with respiratory acidosis. There is no evidence to support the nursing diagnosis Impaired Mobility for this client.
Acute respiratory acidosis can lead to ________, which affects neurological function and the cardiovascular system. A) hypercapnia B) carbon dioxide narcosis C) hypoventilation D) hyperventilation
Answer: A Explanation: A) In acute respiratory acidosis, increased carbon dioxide levels, also called hypercapnia, can affect neurological function and the cardiovascular system. Carbon dioxide narcosis occurs in chronic respiratory acidosis. Hypoventilation causes respiratory acidosis; it doesn't result from respiratory acidosis. Hyperventilation is related to respiratory alkalosis, not respiratory acidosis.
The nurse is providing care to a client recently extubated for treatment of aspiration pneumonia and respiratory acidosis. Which action by the nurse provides an optimum environment for this client? A) Allowing family members to remain with client as much as possible B) Restraining the client C) Placing the client in a side-lying position D) Administering narcotics for pain
Answer: A Explanation: A) The client with respiratory acidosis often experiences anxiety. This client would benefit from having a family member in the room to provide reassurance. Restraining the client will increase levels of agitation. The client with respiratory failure would benefit most from the semi-Fowler or Fowler position to increase ventilation. Narcotics will depress the respirations and increase respiratory acidosis. A nonnarcotic pain reliever would be considered if this client were experiencing pain.
The nurse is assessing an African-American client whose cultural background is different from the cultural background of the nurse. The client has symptoms of metabolic acidosis. Which of the following situations would illustrate stereotypical behavior on the nurse's part? Select all that apply. A) Understanding that all culture members will have the same beliefs B) Bringing previous negative information and experiences into this situation C) Making an assumption that all members of each culture are alike D) Taking general knowledge from literature and applying it to the situation E) Discussing the client's health status with family members
Answer: A, B, C, D A) Understanding that all culture members will have the same beliefs B) Bringing previous negative information and experiences into this situation C) Making an assumption that all members of each culture are alike D) Taking general knowledge from literature and applying it to the situation
The nurse is preparing discharge instructions for an older adult client recovering from respiratory acidosis caused by restrictive lung disease and pneumonia. Which topics should the nurse include in the discharge teaching for this client? Select all that apply. A) Obtain annual influenza immunization. B) Engage in frequent hand washing. C) Avoid crowds. D) Cover the nose and mouth when coughing. E) Restrict fluids.
Answer: A, B, C, D Explanation: A) For the client with a history of chronic lung disease and pneumonia, the nurse should instruct on the importance of receiving annual influenza immunizations, frequent hand washing, avoiding crowds, and covering the nose and mouth when coughing. Fluids should be encouraged to ensure that respiratory secretions are thin.
The nurse is preparing to admit a client with acute pneumonia who is experiencing severe respiratory acidosis. Which treatments does the nurse anticipate as appropriate for this client? Select all that apply. A) Administer oxygen prn. B) Administer digoxin for heart failure. C) Encourage up to 3 L of fluids per day. D) Place in a prone position. E) Reposition frequently.
Answer: A, C, E Explanation: A) The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia. The client should be placed in the Fowler or semi-Fowler rather than the prone position.
The nurse is caring for a client who has been admitted to the hospital for congestive heart failure. Which data collected during the nursing assessment indicates that the client is at risk for metabolic alkalosis? Select all that apply. A) The client takes furosemide (Lasix) daily. B) The client takes a baby aspirin once daily. C) The client takes metformin daily. D) The client frequently uses calcium carbonate (Tums®) for acid indigestion. E) The client takes acetaminophen as needed for pain.
Answer: A, D A) The client takes furosemide (Lasix) daily. D) The client frequently uses calcium carbonate (Tums®) for acid indigestion.
The nurse is caring for a client who has been admitted with persistent diarrhea lasting 3 days. Which of the following are appropriate nursing diagnoses for this client during the acute phase of the illness? Select all that apply. A) Decreased Cardiac Output B) Ineffective Airway Clearance C) Deficient Fluid Volume D) Knowledge Deficit E) Risk for Injury
Answer: A, E A) Decreased Cardiac Output E) Risk for Injury
A client with severe metabolic alkalosis has been admitted to the unit and is being cared for by a nursing student along with the nurse. What should the nurse say is a priority for this client? A) Administering medication for metabolic alkalosis B) Monitoring oxygen saturation C) Teaching the client the risk factors for metabolic alkalosis D) Setting goals for the client with metabolic alkalosis
Answer: B B) Monitoring oxygen saturation
A client with metabolic acidosis has been admitted to the unit from the Emergency Department. The client is experiencing confusion and weakness. Which of the following does the nurse implement as a priority of care for this client? A) Place the client in a high-Fowler's position. B) Protect the client from injury. C) Administer sodium bicarbonate. D) Give the client skin care.
Answer: B B) Protect the client from injury.
The nurse is planning care for the client with Cushing's syndrome who has been admitted for complications related to the disease process. Which intervention should the nurse plan for this client to improve the impaired gas exchange? A) Monitor serum electrolytes. B) Schedule nursing activities to allow for periods of rest. C) Assess input and output accurately. D) Administer IV fluids per practitioner order.
Answer: B B) Schedule nursing activities to allow for periods of rest.
The nurse assumes care for a client who was brought to the hospital after a morphine overdose. What acid-base imbalance does the nurse expect to observe in this client? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis
Answer: B Explanation: A) Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this client is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this client's morphine overdose.
The nurse suspects a client with one functioning lung is developing chronic respiratory acidosis. Which manifestation did the nurse most likely assess in this client? A) Warm, flushed skin B) Daytime sleepiness C) Irritability D) Blurred vision
Answer: B Explanation: A) The manifestations of acute and chronic respiratory acidosis differ. The client with chronic respiratory acidosis will demonstrate daytime sleepiness. The client with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation.
The nurse is caring for a client with metabolic acidosis. Which of the following are appropriate goals for this client? Select all that apply. A) The client will maintain a respiratory rate of 30 or more. B) The client will describe preventative measure for the underlying chronic illness. C) The client will maintain baseline cardiac rhythm. D) pH will range from 7.25 to 7.35. E) The client will take potassium supplements to increase potassium levels.
Answer: B, C B) The client will describe preventative measure for the underlying chronic illness. C) The client will maintain baseline cardiac rhythm.
A client with pneumonia develops respiratory acidosis. Based on provider's orders, which medications should the nurse prepare to administer to this client? Select all that apply. A) The loop diuretic furosemide (Lasix), 20 mg by mouth twice a day B) The antibiotic amoxicillin, 1 gram intravenous every 6 hours C) The bronchodilator albuterol, inhaler 2 puffs every 4 hours D) The anxiolytic diazepam (Valium), 2 mg by mouth at bedtime for sleep E) Potassium chloride 20 mEq in 100 mL 0.9% normal saline intravenous every day
Answer: B, C Explanation: A) Bronchodilator drugs such as an albuterol inhaler may be administered to open the airways, and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this client's respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.
A client is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings should the nurse suspect will confirm this diagnosis? Select all that apply. A) Serum glucose level 142 mg/dL B) Blood pH 7.47 and bicarbonate 34 mEq/L C) Intravenous pyelogram shows kidney stones D) Bilateral lower lobe infiltrates noted on chest x-ray E) Electrocardiogram changes consistent with hypokalemia
Answer: B, E B) Blood pH 7.47 and bicarbonate 34 mEq/L E) Electrocardiogram changes consistent with hypokalemia
The nurse is preparing to discharge a client with congestive heart failure on furosemide (Lasix). The nurse determines that teaching has been effective if the client makes which statement? A) "I will use only sodium bicarbonate as my antacid." B) "I will restrict my intake of fluids." C) "I will use potassium supplements while I am taking Lasix." D) "I will take antacids only for my gastric discomforts."
Answer: C C) "I will use potassium supplements while I am taking Lasix."
While reviewing laboratory results, the nurse notes that a client's potassium level is 2.8 mEq/L and chloride level is 100 mEq/L. How should the nurse plan to support this client's acid-base balance? A) Prepare to administer 0.9% sodium chloride infusion. B) Measure for nasogastric tube insertion. C) Discuss potassium chloride replace therapy with the healthcare provider. D) Review implications of transfusing with ammonia chloride.
Answer: C C) Discuss potassium chloride replace therapy with the healthcare provider.
The client has been vomiting for several days. The nurse knows that the client is at risk for metabolic alkalosis because gastric secretions have which of the following characteristics? A) Gastric secretions are green in color. B) Gastric secretions are alkaline. C) Gastric secretions are acidic. D) Gastric secretions have a foul smell.
Answer: C C) Gastric secretions are acidic.
During a home visit, the nurse evaluates teaching provided to a client recently hospitalized for metabolic alkalosis. Which observation indicates that additional teaching is required? A) Drinks 2 cups of black coffee each day. B) Consumes one orange each day with breakfast. C) Ingests bicarbonate of soda after each meal. D) Monitors and tracks daily weights. `
Answer: C C) Ingests bicarbonate of soda after each meal.
During a home visit, the nurse evaluates care provided to a client with type 1 diabetes mellitus and a history of metabolic acidosis. Which outcome indicates that the care of this client has been successful? A) The client is injecting insulin into thigh muscle. B) The client is taking laxatives three times a week to ensure adequate bowel movements. C) The client is eating three balanced meals per day with two snacks. D) The client is taking aspirin 325 mg every 6 hours to treat arthritis pain.
Answer: C C) The client is eating three balanced meals per day with two snacks.
The nurse is planning care for an older client with respiratory acidosis. Which intervention should the nurse include in this client's plan of care? A) Administer prescribed intravenous fluids carefully. B) Administer intravenous sodium bicarbonate. C) Maintain adequate hydration. D) Reduce environmental stimuli.
Answer: C Explanation: A) In respiratory acidosis, there are a drop in the blood pH, a reduced level of oxygen, and retention of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation. Careful administration of intravenous fluids is important in the older client with metabolic alkalosis because older clients are at risk because of their fragile fluid and electrolyte status. Sodium bicarbonate is indicated in the treatment of metabolic acidosis. Reducing environmental stimuli would be appropriate for the client with respiratory alkalosis.
The nurse is caring for a client who has been admitted to the unit with respiratory failure and respiratory acidosis. Which data from the nursing history would the nurse suspect contributed to the client's current state of health? A) Use of ibuprofen for the control of pain B) A recent trip to South America C) Aspiration pneumonia D) Recent recovery from a cold virus
Answer: C Explanation: A) Aspiration of a foreign body and acute pneumonia would put the client at risk for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk factor. Recent recovery from a cold would not likely put the client at risk. Ibuprofen does not pose a threat to the respiratory health of the client.
Decreased level of consciousness in acute respiratory acidosis is often due to hypercapnia causing: A) decreased pulse rate. B) hyperventilation. C) cerebral vasodilation. D) neurotransmitter disturbances.
Answer: C Explanation: A) Hypercapnia causes cerebral vasodilation, which results in headache, blurred vision, irritability, mental cloudiness, and decreased level of consciousness. The pulse rate is elevated in acute respiratory acidosis, not decreased. Respiratory acidosis is caused by hypoventilation, not hyperventilation. Neurotransmitter disturbances are unrelated to respiratory acidosis.
A client is admitted to the emergency department (ED) for treatment of an overdose. The client's arterial blood gas results indicate acute respiratory acidosis. Which substance found on the nurse's review of the toxicology analysis is most likely the cause for the client's current condition? A) Cocaine (a stimulatory anesthetic) B) Marijuana (a cannabinoid) C) Oxycodone (a narcotic) D) PCP (a dissociative anesthetic)
Answer: C Explanation: A) Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can lead to respiratory depression and respiratory acidosis. Cocaine is a stimulant. Marijuana does not depress the central nervous system or respiratory center. PCP is a hallucinogenic agent.
The nurse is caring for a client who is being mechanically ventilated. The current ventilator settings are: respiratory rate, 25 breaths per minute; tidal volume, 600 mL; FiO2, 30%; humidification 30 mg H2O/L. After being ventilated for 2 hours, arterial blood gas analysis reveals a pH of 7.20 and a PaCO2 of 49 mmHg. Which change in ventilator settings should the nurse anticipate? A) Increase in humidification of inspired air B) Decrease of FiO2 from 30% to 25% C) Increased respiratory rate to 30 breaths per minute D) Decreased tidal volume of each breath
Answer: C Explanation: A) This client is exhibiting respiratory acidosis that is not corrected by the current ventilator settings. This client needs to "blow off" more CO2; therefore, the respiratory rate would be increased. Both decreasing the FiO2 and decreasing the tidal volume would decrease the amount of CO2 expelled. Humidification has no effect on the amount of CO2 expelled.
An Asian-American adolescent is hospitalized following several days of vomiting following food poisoning. The nurse is planning to include which points when teaching the client's family at discharge? Select all that apply. A) Immunizations for the adolescent B) Nutritional patterns of the adolescent C) Signs and symptoms of metabolic alkalosis D) Proper food-handling techniques E) Normal laboratory values of the adolescent
Answer: C, D C) Signs and symptoms of metabolic alkalosis D) Proper food-handling techniques
The nurse is planning care for the client who has been admitted with metabolic alkalosis. Which are appropriate nursing diagnoses for this client during the acute phase of the illness? Select all that apply. A) Ineffective Health Maintenance B) Risk for Hypothermia C) Deficient Fluid Volume D) Risk for Impaired Gas Exchange E) Risk for Injury
Answer: C, D, E C) Deficient Fluid Volume D) Risk for Impaired Gas Exchange E) Risk for Injury
The client is admitted to the emergency department (ED) with symptoms of a panic attack, including hyperventilation. Based on this data, the nurse plans care for which health problem? A) Hypoventilation B) Vomiting C) Respiratory alkalosis D) Memory loss
C
The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis? Select all that apply. A) Apply wrist restraints and secure to the bed frame. B) Discuss chemical restraint use with the healthcare provider. C) Keep the bed in the lowest position. D) Keep bed side rails raised. E) Place a clock and calendar at the bedside.
Answer: C, D, E C) Keep the bed in the lowest position. D) Keep bed side rails raised. E) Place a clock and calendar at the bedside.
Upon entering a room, the nurse quickly scans the environment and then immediately assesses the client for manifestations of metabolic acidosis. What observation did the nurse make that precipitated this assessment of the client? A) Client sleeping with the head of the bed flat B) Half of the client's lunch tray uneaten C) One formed stool in the bedside commode D) 1000 mL of intravenous 0.9% normal saline infused in 2 hours
Answer: D D) 1000 mL of intravenous 0.9% normal saline infused in 2 hours
The nurse is reviewing orders written by the healthcare provider for a client with metabolic acidosis. Which order should the nurse question before implementing it for the client? A) Begin intravenous infusion of 0.9% normal saline. B) Draw serum potassium levels every 2 hours. C) Draw arterial blood gas samples every 2 hours. D) Administer 1 ampule of sodium bicarbonate now.
Answer: D D) Administer 1 ampule of sodium bicarbonate now.
The nurse instructs a client with a history of acute respiratory acidosis and lung infections on ways to prevent further episodes of the health problem. Which client statement indicates that teaching has been effective? A) "I will limit drinking alcohol to the evening hours only." B) "I will limit my intake of bananas and oranges." C) "I will take prescribed antibiotics until my symptoms subside." D) "I will receive the annual influenza vaccination."
Answer: D Explanation: A) The nurse should discuss ways to avoid future episodes of acute respiratory infections by encouraging the client to receive immunization against pneumococcal pneumonia and influenza. Alcohol is a central nervous system depressant, which can adversely affect respiratory status and lead to the development of respiratory acidosis. The ingestion of bananas and oranges will not promote the development of respiratory acidosis. The client should be instructed to complete a full course of antibiotics prescribed to treat infections.
The nurse is reviewing prescriptions written for a client with chronic respiratory acidosis. Which prescription should the nurse question prior to implementation? A) Keep head of the bed elevated to 40-degree angle. B) Dextrose 5% and 0.45% normal saline at 100 mL per hour C) Consult Respiratory Therapy for breathing treatments four times a day. D) Oxygen 6 liters per minute per nasal cannula
Answer: D Explanation: A) In clients with chronic respiratory acidosis, oxygen is administered cautiously to prevent carbon dioxide narcosis. Adequate hydration such as intravenous fluids is important to promote removal of respiratory secretions. Pulmonary hygiene measures such as breathing treatments may be instituted. Elevating the head of the bed promotes oxygenation.
A client begins to hyperventilate after learning that a breast biopsy was positive for cancer. After a few minutes, the client loses consciousness. Which action by the nurse is the priority? A) Begin cardiopulmonary resuscitation. B) Raise the side rails on the bed. C) Notify the physician. D) Insert an intravenous access device.
B
A client is brought to the emergency department (ED) with rapid breathing after learning of a family member being killed in a house fire. What should the nurse do first to help this client? A) Coach to slow the breathing. B) Move to a quiet, calm environment. C) Provide a sedative. D) Ask for a psychiatric consultation.
B
A client with metabolic alkalosis is experiencing numbness around the mouth and tingling of the fingers. What should the nurse explain as the reason for these manifestations? A) "Because you are breathing so fast, the oxygen is not getting to your nerve endings." B) "Your health problem affects calcium in your body, which causes the tingling around your mouth and fingers." C) "You have a buildup of carbon dioxide in your blood." D) "You don't have enough potassium in your body, so the tingling around your mouth and fingers will occur."
B
The most common disorder that increases a client's risk for respiratory alkalosis is: A) a respiratory disorder. B) an anxiety disorder. C) a cardiovascular disorder. D) a congenital disorder.
B
The nurse is providing care to an older adult client diagnosed with respiratory alkalosis. The nurse states to the client, "Look into my eyes and breathe with me so that we can slow down your breathing rate." The client continues to look down and refuses to make eye contact with the nurse. The client's daughter later asks you to teach her how to help her mother to control her breathing. When documenting this client's care, which statement is appropriate for the nurse to include? A) "The client is noncompliant with suggested treatment plan." B) "The client is unable to understand and follow directions." C) "The client did not feel comfortable making eye contact during nursing care." D) "The client's daughter may be abusive."
C
11) The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis? Select all that apply. A) Apply wrist restraints and secure to the bed frame. B) Discuss chemical restraint use with the healthcare provider. C) Keep the bed in the lowest position. D) Keep bed side rails raised. E) Place a clock and calendar at the bedside.
C, D, E
The nurse is reviewing new orders written for a client experiencing respiratory alkalosis. Which orders would be appropriate for this client's care needs? Select all that apply. A) Oxygen 2 liters via face mask B) Restrict fluids to 2 liters per day. C) Admit to a private room. D) Infuse 1 ampule of sodium bicarbonate now. E) Draw arterial blood gases.
CE
A 2-month-old infant has been diagnosed with pneumonia with respiratory alkalosis. The provider also suspects that the infant is suffering from paresthesias of the hands and feet, because the infant pulls away and cries when his extremities are touched. What client teaching can the nurse provide the parents to comfort the infant with paresthesias? A) Postural drainage techniques B) Massage techniques C) Breastfeeding techniques D) Swaddling techniques
D
The mother of a 1-month-old infant calls the nurse who works in the health clinic. The mother is concerned because the infant has had vomiting and diarrhea for 2 days. The nurse knows that this infant is at risk for metabolic acidosis. Which of the following is the priority nursing action? A) Instruct the mother to provide the infant with 50 mL of glucose water. B) Instruct the mother to measure the infant's urine output for 24 hours. C) Instruct the mother to give the infant at least 2 ounces of juice every 2 hours. D) Instruct the mother to bring the infant to the clinic for evaluation.
D) Instruct the mother to bring the infant to the clinic for evaluation.
10) The nurse is identifying a diagram to use to explain a client's acid-base balance. Which imbalance does the following diagram suggest is occurring with the client? 1 part H2CO3< 18 parts bicarbonate HCO3- A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
a
3) A 10-year-old boy has been admitted to the hospital with respiratory acidosis. The nurse suspects that which chronic lung disease most likely caused the child to develop this condition? A) Cystic fibrosis B) Aspiration C) Hyperthyroidism D) Pneumonia
a
4) A client has been admitted to the unit with chronic obstructive pulmonary disease. Blood gas analysis indicates respiratory acidosis. The nurse anticipates which diagnosis should be the priority for this client? A) Impaired Gas Exchange B) Ineffective Airway Clearance C) Impaired Mobility D) Anxiety
a
5) A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the client's acid-base balance? A) Arterial blood gases (ABGs) B) Pulse oximetry C) Sputum studies D) Bronchoscopy
a
6) The nurse is caring for a client admitted with renal failure and metabolic acidosis. Which of the following signs would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective? A) Decreased respiratory depth B) Palpitations C) Increased deep tendon reflexes D) Respiratory rate of 38
a
8) A client with hyperaldosteronism has been admitted to the unit. The nurse knows the client is at risk for impaired gas exchange. Which position should this client be placed to enhance gas exchange? A) Fowler's position B) Prone position C) Left side-lying position D) Right Sims position
a
Exemplar 1.1 Metabolic Acidosis 1) The nurse is analyzing the client's arterial blood gas report, which reveals a pH of 6.58. The client has just suffered a cardiac arrest. Which of the following consequences does the nurse consider for this client? A) Decreased cardiac output B) Increase magnesium levels C) Decreased free calcium in the ECT D) Increased myocardial contractility
a
The Concept of Acid-Base Balance 1) A client is brought to the Emergency Department after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client? A) Metabolic acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Respiratory acidosis
a
3) The nurse is assessing an African-American client whose cultural background is different from the cultural background of the nurse. The client has symptoms of metabolic acidosis. Which of the following situations would illustrate stereotypical behavior on the nurse's part? Select all that apply. A) Understanding that all culture members will have the same beliefs B) Bringing previous negative information and experiences into this situation C) Making an assumption that all members of each culture are alike D) Taking general knowledge from literature and applying it to the situation E) Discussing the client's health status with family members
a, b, c, d
10) The nurse identifies the diagnosis Risk for Impaired Gas Exchange to guide the care of a client with metabolic alkalosis. What did the nurse assess to support this diagnosis? Select all that apply. A) Respiratory rate 8 per minute B) Oxygen saturation 89% C) Urine output 25 mL/hr D) Restlessness and agitation E) Weight loss of 3 kg overnight
a, b, d
7) The nurse is caring for the client experiencing hypovolemic shock and metabolic acidosis. Which of the following therapies would the nurse question if planned for this client? Select all that apply. A) Monitor weight on admission and discharge. B) Monitor ECG for conduction problems. C) Limit the intake of fluids. D) Administer sodium bicarbonate. E) Keep the bed in the locked and low position
a, c
2) The nurse is caring for a client who has been admitted to the hospital for congestive heart failure. Which data collected during the nursing assessment indicates that the client is at risk for metabolic alkalosis? Select all that apply. A) The client takes furosemide (Lasix) daily. B) The client takes a baby aspirin once daily. C) The client takes metformin daily. D) The client frequently uses calcium carbonate (Tums®) for acid indigestion. E) The client takes acetaminophen as needed for pain.
a, d
2) Which of the following risk factors exhibited by the client presenting in the Emergency Department would place the client at risk for metabolic acidosis? Select all that apply. A) Abdominal fistulas B) Chronic obstructive pulmonary disease C) Pneumonia D) Acute renal failure E) Hypovolemic shock
a, d, e
7) A client who was diagnosed with diabetes mellitus 1 year ago is hospitalized in diabetic ketoacidosis after a religious fast. The client tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable about this particular religion. Which nursing action would be appropriate? Select all that apply. A) Request a consult from a diabetes educator. B) Tell the client that things are different now because of the diabetes. C) Ask family members of the same religion to discuss fasting with the client. D) Assess the meaning and context of fasting in the client's religion. E) Encourage the client to seek medical care if signs of ketoacidosis occur in the future
a, d, e
4) The nurse is caring for a client who has been admitted with persistent diarrhea lasting 3 days. Which of the following are appropriate nursing diagnoses for this client during the acute phase of the illness? Select all that apply. A) Decreased Cardiac Output B) Ineffective Airway Clearance C) Deficient Fluid Volume D) Knowledge Deficit E) Risk for Injury
a, e
5) The nurse is planning care for the client with Cushing's syndrome who has been admitted for complications related to the disease process. Which intervention should the nurse plan for this client to improve the impaired gas exchange? A) Monitor serum electrolytes. B) Schedule nursing activities to allow for periods of rest. C) Assess input and output accurately. D) Administer IV fluids per practitioner order
b
7) A client with severe metabolic alkalosis has been admitted to the unit and is being cared for by a nursing student along with the nurse. What should the nurse say is a priority for this client? A) Administering medication for metabolic alkalosis B) Monitoring oxygen saturation C) Teaching the client the risk factors for metabolic alkalosis D) Setting goals for the client with metabolic alkalosis
b
8) A client with metabolic acidosis has been admitted to the unit from the Emergency Department. The client is experiencing confusion and weakness. Which of the following does the nurse implement as a priority of care for this client? A) Place the client in a high-Fowler's position. B) Protect the client from injury. C) Administer sodium bicarbonate. D) Give the client skin care.
b
Exemplar 1.3 Respiratory Acidosis 1) The nurse has admitted a client who was brought to the hospital after a morphine overdose. What acid-base imbalance does the nurse expect to observe in this client? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis
b
5) The nurse is caring for a client with metabolic acidosis. Which of the following are appropriate goals for this client? Select all that apply. A) The client will maintain a respiratory rate of 30 or more. B) The client will describe preventative measure for the underlying chronic illness. C) The client will maintain baseline cardiac rhythm. D) pH will range from 7.25 to 7.35. E) The client will take potassium supplements to increase potassium levels
b, c
11) A client is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings should the nurse suspect will confirm this diagnosis? Select all that apply. A) Serum glucose level 142 mg/dL B) Blood pH 7.47 and bicarbonate 34 mEq/L C) Intravenous pyelogram shows kidney stones D) Bilateral lower lobe infiltrates noted on chest x-ray E) Electrocardiogram changes consistent with hypokalemia
b, e
11) The nurse is planning care for an older client with respiratory acidosis. Which intervention should the nurse include in this client's plan of care? A) Administer prescribed intravenous fluids carefully. B) Administer intravenous sodium bicarbonate. C) Maintain adequate hydration. D) Reduce environmental stimuli
c
12) During an assessment, the nurse becomes concerned that a client is at risk for developing metabolic alkalosis. What did the nurse assess that caused this concern? A) Daily ingestion of a banana with breakfast B) Daily weight consistent C) Daily use of sodium bicarbonate for gastric upset D) Daily use of prescribed NSAIDs for arthritic pain
c
13) During a home visit, the nurse evaluates care provided to a client with type 1 diabetes mellitus and a history of metabolic acidosis. Which outcome indicates that the care of this client has been successful? A) The client is injecting insulin into thigh muscle. B) The client is taking laxatives three times a week to ensure adequate bowel movements. C) The client is eating three balanced meals per day with two snacks. D) The client is taking aspirin 325 mg every 6 hours to treat arthritis pain.
c
13) During a home visit, the nurse evaluates teaching provided to a client recently hospitalized for metabolic alkalosis. Which observation indicates that additional teaching is required? A) Drinks 2 cups of black coffee each day. B) Consumes one orange each day with breakfast. C) Ingests bicarbonate of soda after each meal. D) Monitors and tracks daily weights.
c
13) The nurse is caring for a comatose client with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this client? A) Measuring vital signs B) Measuring intake and output C) The client's recent eating behaviors D) Identifying current oxygen saturation level
c
2) The nurse is caring for a client who has been admitted to the unit with respiratory failure and respiratory acidosis. What data from the nursing history would the nurse suspect contributed to the client's current state of health? A) Use of ibuprofen for the control of pain B) A recent trip to South America C) Aspiration pneumonia D) Recent recovery from a cold virus
c
3) A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets this as which of the following? A) Metabolic acidosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic alkalosis
c
6) The nurse is instructing a client with a history of acidosis on the use of sodium bicarbonate. Which client statement indicates that additional teaching is needed? A) "I should contact the doctor if I have any gastric discomfort with chest pain." B) "I need to purchase antacids without salt." C) "I should use the antacid for at least 2 months." D) "I should call the doctor if I get short of breath or start to sweat with this medication."
c
6) The nurse is preparing to discharge a client with congestive heart failure on furosemide (Lasix). The nurse determines that teaching has been effective if the client makes which statement? A) "I will use only sodium bicarbonate as my antacid." B) "I will restrict my intake of fluids." C) "I will use potassium supplements while I am taking Lasix." D) "I will take antacids only for my gastric discomforts."
c
8) The client is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the client to be lethargic, confused, and breathing rapidly. What is the nurse's priority response to the situation? A) Stop the infusion and notify the physician because the client is in alkalosis. B) Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis. C) Continue the infusion, because the client is still in acidosis, and notify the physician. D) Increase the rate of the infusion and continue to assess the client for symptoms of acidosis
c
9) While reviewing laboratory results, the nurse notes that a client's potassium level is 2.8 mEq/L and chloride level is 100 mEq/L. How should the nurse plan to support this client's acid-base balance? A) Prepare to administer 0.9% sodium chloride infusion. B) Measure for nasogastric tube insertion. C) Discuss potassium chloride replace therapy with the healthcare provider. D) Review implications of transfusing with ammonia chloride.
c
Exemplar 1.2 Metabolic Alkalosis 1) The client has been vomiting for several days. The nurse knows that the client is at risk for metabolic alkalosis because gastric secretions have which of the following characteristics? A) Gastric secretions are green in color. B) Gastric secretions are alkaline. C) Gastric secretions are acidic. D) Gastric secretions have a foul smell.
c
3) An Asian-American adolescent is hospitalized following several days of vomiting following food poisoning. The nurse is planning to include which points when teaching the client's family at discharge? Select all that apply. A) Immunizations for the adolescent B) Nutritional patterns of the adolescent C) Signs and symptoms of metabolic alkalosis D) Proper food-handling techniques E) Normal laboratory values of the adolescent
c, d
4) The nurse is planning care for the client who has been admitted with metabolic alkalosis. Which are appropriate nursing diagnoses for this client during the acute phase of the illness? Select all that apply. A) Ineffective Health Maintenance B) Risk for Hypothermia C) Deficient Fluid Volume D) Risk for Impaired Gas Exchange E) Risk for Injury
c, d, e
10) The nurse is reviewing orders written by the healthcare provider for a client with metabolic acidosis. Which order should the nurse question before implementing it for the client? A) Begin intravenous infusion of 0.9% normal saline. B) Draw serum potassium levels every 2 hours. C) Draw arterial blood gas samples every 2 hours. D) Administer 1 ampule of sodium bicarbonate now
d
12) The results of a client's arterial blood gas sample reveal an oxygen level of 72 mmHg. For which associated health problem should the nurse assess this client? A) Communication B) Perfusion C) Fluid and electrolyte imbalance D) Cognition
d
2) The mother of a 1-month-old infant calls the nurse who works in the health clinic. The mother is concerned because the infant has had vomiting and diarrhea for 2 days. The nurse knows that this infant is at risk for metabolic acidosis. Which of the following is the priority nursing action? A) Instruct the mother to provide the infant with 50 mL of glucose water. B) Instruct the mother to measure the infant's urine output for 24 hours. C) Instruct the mother to give the infant at least 2 ounces of juice every 2 hours. D) Instruct the mother to bring the infant to the clinic for evaluation
d
4) The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? A) pH 7.32 B) PaCO2 18 mmHg C) HCO3 8 mEq/L D) PaCO2 48 mmHg
d
Upon entering a room, the nurse quickly scans the environment and then immediately assesses the client for manifestations of metabolic acidosis. What observation did the nurse make that precipitated this assessment of the client? A) Client sleeping with the head of the bed flat B) Half of the client's lunch tray uneaten C) One formed stool in the bedside commode D) 1000 mL of intravenous 0.9% normal saline infused in 2 hours
d
