Module 9 Acid-Base Balance
Which effect of sodium bicarbonate is the nurse trying to prevent when teaching a client about the dangers of using sodium bicarbonate regularly? A. Gastric distention B. Metabolic alkalosis C. Chronic constipation D. Cardiac dysrhythmias
B. Metabolic alkalosis Rationale: Prolonged use of sodium bicarbonate may cause systemic alkalosis, as well as retention of sodium and water. Gastric distention is not an effect of sodium bicarbonate. Chronic constipation is not an effect of sodium bicarbonate. Cardiac dysrhythmias are not an effect of sodium bicarbonate.
Which complication would the nurse prevent by addressing the needs of a hyperventilating client? A. Cardiac arrest B. Carbonic acid deficit C. Reduction in serum pH D. Excess oxygen saturation
B. Carbonic acid deficit Rationale: Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience dysrhythmias but eventually will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis, so the pH is increased rather than reduced. Excess oxygen saturation cannot occur; normal oxygen saturation of hemoglobin is 95% to 98%.
The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. Which urinary finding indicates the need to notify the primary health care provider? A. Acidic pH B. Glucose negative C. Bacteria negative D. Presence of large proteins
D. Presence of large proteins Rationale: The glomeruli are not permeable to large proteins such as albumin or red blood cells, and finding them in the urine is abnormal; the nurse would report their presence to the primary health care provider to modify the client's treatment plan. The urine can be acidic; normal pH is 4.0 to 8.0. Glucose and bacteria should be negative and are normal findings.
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor which laboratory results? A. Sodium and chloride levels B. Bicarbonate and sulfate levels C. Magnesium and protein levels D. Calcium and phosphate levels
A. Sodium and chloride levels Rationale: Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.
Which process is the origin of metabolic acidosis caused by aspirin toxicity? A. Deep, rapid breathing B. Higher pH of gastric contents C. Rapid absorption of salicylate D. Increased renal excretion of bicarbonate
C. Rapid absorption of salicylate Rationale: Rapid absorption of acetylsalicylic acid (aspirin) causes the stomach contents to become more acidic, leading to metabolic acidosis. Hyperventilation is the body's attempt to blow off excess hydrogen ions; carbon dioxide is converted to hydrogen ions by way of the carbonic anhydrase reaction. The pH of the stomach contents decreases with aspirin toxicity, becoming more acidic, resulting in metabolic acidosis. Although increased renal excretion of bicarbonate can contribute to metabolic acidosis, this is not the mechanism associated with aspirin toxicity. In metabolic acidosis associated with aspirin toxicity the kidneys attempt to decrease the renal excretion of bicarbonate
The nurse is caring for a client after abdominal surgery and encourages the client to engage in deep-breathing exercises and turn from side to side. Which complication is the nurse trying to prevent? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C. Respiratory acidosis Rationale: Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. Breathing is deep, rapid, and unlabored. Stools are liquid and there has been no obvious urine output. Which problem would the nurse be concerned about? A. Kidney failure B. Mild dehydration C. Metabolic acidosis D. Respiratory alkalosis
C. Metabolic acidosis Rationale: Metabolic acidosis occurs with loss of alkaline fluid through diarrhea and is manifested by lethargy and Kussmaul breathing; all of the assessments indicate severe dehydration. The infant has not urinated because excessive amounts of fluid have been lost in the loose stools; this indicates that the kidneys are functioning by compensating for the fluid loss. All data indicate a severe, not mild, fluid volume deficiency. Respiratory alkalosis is caused by an excessive loss of carbon dioxide, not alkaline loss from diarrhea.
A client is hospitalized after 4 days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, pCO 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). Which condition does the nurse determine the results indicate? A. Hypernatremia B. Hyperchloremia C. Metabolic alkalosis D. Respiratory acidosis
C. Metabolic alkalosis Rationale: The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23-25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135-145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95-105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis, the pH is decreased to less than 7.35.
A client arrives in the emergency department with epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Which is the primary nursing concern? A. Acute pain B. Risk for injury C. Metabolic alkalosis D. Ineffective breathing
C. Metabolic alkalosis Rationale: Prolonged vomiting results in fluid loss and acid (hydrochloric) loss; the client's symptoms reflect dehydration and metabolic alkalosis. Although it is important to address the client's pain, the fluid and electrolyte/acid/base imbalance must be addressed first because it can be life threatening. Although risk for injury is a potential problem, the priority is the fluid and electrolyte/acid/base problem. The ineffective breathing pattern most likely is caused by the metabolic alkalosis; the fluid and electrolyte/acid/base imbalance is a higher priority and must be addressed first.
The assessment of a newly admitted client reveals malnourishment, nausea, distension, and a firm abdomen with ascites. The client has tachycardia and is hypotensive. Which physiological change occurred that resulted in the client's development of ascites? A. An increase in vitamins to maintain cell coenzyme functions B. An increase in iron to maintain adequate hemoglobin synthesis C. A decrease in sodium to maintain its concentration in tissue fluid D. A decrease in plasma protein to maintain adequate capillary-tissue circulation
D. A decrease in plasma protein to maintain adequate capillary-tissue circulation Rationale: Malnutrition and liver damage lead to a reduced serum albumin level and failure of the capillary fluid shift mechanism, resulting in ascites. Vitamins are unrelated to ascites. Iron promotes hemoglobin synthesis, which is unrelated to cirrhosis. The sodium level is usually excessive with cirrhosis.
A high school student arrives at the local blood drive center to donate blood for the first time and as the site is being prepared for needle insertion, the student becomes agitated and starts to hyperventilate. Which instruction would the nurse provide the student? A. Breathe into cupped hands. B. Pant using rapid, shallow breaths. C. Use a rapid deep-breathing pattern. D. Hold the breath for as long as possible
A. Breathe into cupped hands. Rationale: Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.
Which independent nursing action would be included in the plan of care for a client after an episode of ketoacidosis? A. Monitoring for signs of hypoglycemia resulting from treatment B. Withholding glucose in any form until the situation is corrected C. Giving fruit juices, broth, and milk as soon as the client is able to take fluids orally D. Regulating insulin dosage according to the client's urinary ketone levels
A. Monitoring for signs of hypoglycemia resulting from treatment Rationale: During treatment for ketoacidosis, hypoglycemia may develop; careful observation for this complication will be made by the nurse. Withholding all glucose may cause insulin coma. Whole milk and fruit juices are high in carbohydrates, which are contraindicated immediately following ketoacidosis. The regulation of insulin depends on the prescription for coverage; the prescription usually depends on the client's blood glucose level rather than ketones in the urine.
What is the sequence of events that occurs in the child's respiratory response to acidosis? Place the physiologic responses in the order in which they occur. 1. Hyperventilation B. Increased CO2 elimination C. Decreased blood H+ ions D. Increased pH
Rationale: Respiratory compensation to acidosis involves hyperventilation with increased CO2 elimination. As CO2 is blown off there is a decrease in the hydrogen ions in the blood, leading to an increase in pH to expected limits
The nurse is caring for a client who is vomiting. When caring for this client, the nurse recalls that the vomiting reflex follows a set pattern. List the steps in the order that they occur. 1. Initiation of reverse peristalsis in the stomach 2. Contraction of abdominal muscles 3. Closure of the trachea to prevent aspiration 4. Relaxation of the upper esophageal sphincter
Rationale: Reverse peristalsis starts the sequence; with contraction of the abdominal muscles, gastric contents are propelled into the esophagus, and the upper esophageal sphincter relaxes so vomiting can occur. Finally, the trachea closes to prevent aspiration.
Which unique response is associated with diabetic ketoacidosis (DKA) that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? A. Fluid loss B. Glycosuria C. Kussmaul respirations D. Increased blood glucose level
Rationale: Kussmaul respirations occur in diabetic ketoacidosis (DKA) as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.
Which statement made by the nurse is accurate about the manifestation of alkalosis in the central nervous system? A. "A client's Chvostek sign would be negative." B. "A client's Trousseau sign would be positive." C. "A client would be suffering from paresthesia." D. "A client would show signs of anxiety and irritability." E. "A client's central nervous system should have decreased activity."
B. "A client's Trousseau sign would be positive." C. "A client would be suffering from paresthesia." D. "A client would show signs of anxiety and irritability." Rationale: If clients suffer from alkalosis, central nervous system activity increases, which manifests as a positive Trousseau sign, paresthesias, anxiety, and irritability. The Chvostek sign would also be positive, not negative.
The nurse is caring for a child with severe dehydration and its associated acid-base imbalance. Which compensatory mechanism within the body is activated to counteract the effects of the child's acid-base imbalance? A. Profuse diaphoresis B. Increased temperature C. Increased respiratory rate D. Renal retention of hydrogen ions
C. Increased respiratory rate Rationale: The child has metabolic acidosis; the lungs compensate by blowing off excess carbonic acid in the form of carbon dioxide. Diaphoresis is a compensatory mechanism to reduce fever by evaporation, not to compensate for metabolic acidosis. Fever is not a compensatory mechanism to counter metabolic acidosis; fever with dehydration results from inadequate fluid for perspiring and cooling. The kidneys excrete hydrogen and ammonium ions to compensate for metabolic acidosis.
The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO 2 80 mm Hg (10.64 kPa), PaCO 2 55 mm Hg (7.32 kPa), and HCO 3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? A. Hypoxemia B. Hypocapnia C. Compensated metabolic acidosis D. Uncompensated respiratory acidosis
D. Uncompensated respiratory acidosis Rationale: The increased PaCO 2 indicates respiratory acidosis and the low pH indicates that the respiratory acidosis is uncompensated. The PaO 2 is normal, indicating that the client is not hypoxemic. The elevated PaCO 2 indicates hypercapnia. The HCO 3 is normal, indicating that there is no metabolic acidosis.
Which condition is a cardiovascular manifestation of alkalosis? (SATA) A. Increased heart rate B. Decreased heart rate C. Widened QRS complex D. Increased digitalis toxicity E. Prolonged PR interval
A. Increased heart rate D. Increased digitalis toxicity Rationale: Increased heart rate and digitalis toxicity are cardiovascular manifestations of alkalosis. Delayed electrical conduction is a cardiovascular manifestation of acidosis, which could result in decreased heart rate, widened QRS complexes, and prolonged PR intervals.
An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus? A. Ketones B. Glucose C. Lactic acid D. Glutamic acid
A. Ketones Rationale: The ketones produced excessively in diabetes are a byproduct of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis. Glucose does not change the pH. Lactic acid is produced as a result of muscle contraction; it is not unique to diabetes. Glutamic acid is a product of protein metabolism.
Which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
A. Metabolic acidosis Rationale: Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. As shock progresses, eventually respiratory acidosis can result from decreased respiratory function in late shock. Respiratory alkalosis may occur as a result of hyperventilation during early shock.
When ammonia is excreted by healthy kidneys, which mechanism usually is maintained? A. Osmotic pressure of the blood B. Acid-base balance of the body C. Low bacterial levels in the urine D. Normal red blood cell production
A. Osmotic pressure of the blood Rationale: The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance. Osmotic pressure of the blood and normal red blood cell production are not affected by excretion of ammonia. Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels
Which ion is the regulator of extracellular osmolarity? A. Sodium B. Potassium C. Chloride Calcium
A. Sodium Rationale: Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.
Which statement made by the client identifies a regulatory function of the kidney? (SATA) A. "Erythropoiesis." B. "Acid-base balance." C. "Vitamin D activation." D. "Blood pressure control." E. "Fluid and electrolyte balance.
B. "Acid-base balance." E. "Fluid and electrolyte balance. Rationale: Maintaining the acid-base balance of the body by selectively reabsorbing and secreting certain substances from the blood is a regulatory function of the kidneys. The kidneys also perform the regulatory function of electrolyte balance by regulating the reabsorption of certain electrolytes while eliminating others depending on their levels in the serum. The kidneys perform hormonal function by secreting a hormone called erythropoietin that aids in synthesis of red blood cells (erythropoiesis). Activation of vitamin D is a hormonal function of the kidneys. The kidneys perform hormonal function by secreting the hormone renin that assists in blood pressure control.
An infant has been vomiting after each feeding, and the physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. Which process would the nurse suspect as causing the infant's acid-base imbalance? A. Retention of potassium in the cells B. Loss of fluid by way of the kidneys C. Loss of chloride ions through vomiting D. Reduction of blood supply to body cells
C. Loss of chloride ions through vomiting Rationale: Electrolyte deficits, rather than urinary excretion, precipitate an acid-base imbalance. Loss of gastric secretions, which contain sodium, chloride, and potassium, usually results in metabolic alkalosis. With vomiting, depletion (not retention) of cellular potassium occurs. Electrolyte deficits, rather than inadequate blood supply, can precipitate an acid-base imbalance.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C. Respiratory acidosis Rationale: The pH indicates acidosis; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.
Which information would the nurse include when teaching a client about the administration of ranitidine? A. Ranitidine increases gastrointestinal peristalsis. B. Ranitidine reduces gastric acidity in the stomach. C. Ranitidine neutralizes the acid that is present in the stomach. D. Ranitidine stops the production of hydrochloric acid in the stomach.
B. Ranitidine reduces gastric acidity in the stomach. Rationale: Ranitidine inhibits histamine at H 2-receptor sites in the stomach, resulting in reduced gastric acid secretion. Ranitidine does not increase gastrointestinal peristalsis, and it does not completely stop the production of hydrochloric acid in the stomach. Ranitidine reduces, rather than neutralizes, gastric acidity
Which chemical buffers excessive acetoacetic acid? A. Potassium B. Sodium bicarbonate C. Carbon dioxide D. Sodium chloride
B. Sodium bicarbonate Rationale: Sodium bicarbonate is a base and one of the major buffers in the body. Potassium, a cation, is not a buffer; only a base can buffer an acid. Carbon dioxide is carried in aqueous solution as carbonic acid (H2CO3); an acid does not buffer another acid. Sodium chloride is not a buffer; it is a salt.
Which condition will improve if an intravenous (IV) solution of lactated Ringer solution to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration is effective? A. Urinary stasis B. Paralytic ileus C. Metabolic acidosis D. Increased potassium level
C. Metabolic acidosis Rationale: Lactated Ringer solution is an alkaline solution that replaces bicarbonate ions lost from T-tube bile drainage, thus preventing or treating acidosis. Urinary stasis is unrelated to the effectiveness of the administration of IV lactated Ringer solution. Paralytic ileus is unrelated to the effectiveness of the administration of IV lactated Ringer solution. An increased potassium level is unrelated to the effectiveness of the administration of IV lactated Ringer solution.
Which medication corrects for deleterious effects of anaerobic energy production when a client's cells are deprived of oxygen during a cardiac arrest? A. Regular insulin B. Calcium gluconate C. Potassium chloride D. Sodium bicarbonate
D. Sodium bicarbonate Rationale: In the absence of oxygen, the body derives its energy anaerobically; this results in a buildup of lactic acid. Sodium bicarbonate, an alkaline medication, will help neutralize the acid, raising the pH. Insulin is used to treat diabetes; it lowers blood sugar by facilitating transport of glucose across cell membranes. Calcium gluconate is used to treat hypocalcemia. Although potassium is essential for cardiac function, it will not correct acidosis. With acidosis, serum hydrogen ions will exchange with intracellular potassium, leading to a temporary hyperkalemic state; therefore potassium chloride is contraindicated until acidosis is corrected.
Which complication would the nurse monitor for when caring for an infant with intractable vomiting? A. Acidosis B. Alkalosis C. Hyperkalemia D. Hypernatremia
B. Alkalosis Rationale: Excessive vomiting causes an increased loss of hydrogen ions (hydrochloric acid), leading to metabolic alkalosis, an excess of base bicarbonate. Acidosis is caused by retention of hydrogen ions and a loss of base bicarbonate, which is more likely to occur with diarrhea. Hypokalemia, not hyperkalemia, will occur because of renal potassium excretion. With the loss of chloride ions, hyponatremia is more likely to occur.
A client appears anxious, exhibiting 40 shallow respirations per minute. The client reports dizziness, light-headedness, and tingling sensations of the fingertips and around the lips. The nurse concludes that the client' s symptoms are most likely related to which condition? A. Eupnea B. Hyperventilation C. Kussmaul respirations D. Carbon dioxide intoxication
B. Hyperventilation Rationale: The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these adaptations; if uninterrupted, this can result in respiratory alkalosis. Eupnea is normal, quiet breathing; the client has shallow, rapid breathing. Kussmaul respirations are deep, gasping respirations associated with diabetic acidosis and coma. These adaptations are related to a decreased carbon dioxide level in the body.
The nurse is caring for a client with the following arterial blood gas (ABG) values: PO 2 89 mm Hg, PCO 2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? A. Respiratory alkalosis B. Poor oxygen perfusion C. Normal acid-base balance D. Compensated metabolic acidosis
C. Normal acid-base balance Rationale: All data are within expected limits; PO 2 is 80 to 100 mm Hg, PCO 2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen (PO 2) is within the expected limits of 80 to 100 mm Hg. With respiratory alkalosis, the blood pH is greater than 7.45 and the PCO 2 is greatly decreased. With metabolic acidosis, the pH is less than 7.35.
The nurse recognizes which statements are true regarding the pharmacokinetic changes observed in infants? (SATA) A. An infant's fat content is higher. B. An infant's gastric pH is less acidic. C. An infant's gastric emptying is slow. D. An infant's first-pass metabolism is slow. E. An infant's transdermal absorption is rapid.
B. An infant's gastric pH is less acidic. C. An infant's gastric emptying is slow. D. An infant's first-pass metabolism is slow. Rationale: Pharmacokinetic changes are observed in infants. An infant's gastric pH is less acidic because the acid-producing cells in the stomach are immature. Gastric emptying is slow due to irregular peristalsis. First-pass metabolism in the liver is slow because the liver is immature and has low levels of microsomal enzymes. An infant's fat content is low because of the high levels of total body water. Transdermal absorption is not affected by age.
Which blood gas report most likely reflects the acid-base balance of an infant with severe dehydration?term-19 A. pH of 7.50 and Pco2 of 34 mm Hg B. pH of 7.23 and Pco2 of 70 mm Hg C. pH of 7.20 and HCO3 of 20 mEq/L (20 mmol/L) D. pH of 7.56 and HCO3 of 30 mEq/L (30 mmol/L)
C. pH of 7.20 and HCO3 of 20 mEq/L (20 mmol/L) Rationale: Low blood pH and bicarbonate levels indicate metabolic acidosis, which occurs with severe dehydration because the reduced urine output causes retention of hydrogen ions. The other options include findings that indicate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis, respectively.
An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. Which physiologic imbalance would the nurse most likely encounter? (SATA) A. Hypovolemia B. Hyperkalemia C. Hypercalcemia D. Metabolic acidosis E. Decreased hematocrit
A. Hypovolemia D. Metabolic acidosis Rationale: Fluid loss causes hypovolemia. Loss of bicarbonate and sodium in the stools causes metabolic acidosis. Potassium will be lost with diarrhea. Sodium may be increased, decreased, or unchanged. Hypercalcemia does not occur. The hematocrit is increased because of fluid loss (hemoconcentration).
Which statement made by the nurse about neuromuscular manifestations of alkalosis with hypocalcemia is correct? A. "The client would show signs of twitching." B. "The client would show signs of hyporeflexia." C. "The client would show signs of paresthesia." D. "The client would show signs of muscle cramping." E. "The client would show signs of skeletal muscle weakness.
A. "The client would show signs of twitching." D. "The client would show signs of muscle cramping." E. "The client would show signs of skeletal muscle weakness. Rationale: The neuromuscular manifestation of alkalosis can be observed through twitching, muscle cramping, and skeletal muscle weakness. The neuromuscular manifestation of alkalosis hypocalcemia is hyperreflexia, not hyporeflexia. Paresthesias is a symptom of alkalosis, which is manifested in the central nervous system, not the neuromuscular system.
How can the nurse prevent vomiting in a client who reports feeling nauseated after cataract surgery? A. Administer the prescribed antiemetic medication. B. Provide some dry crackers for the client to eat. C. Explain that this is expected after surgery. D. Teach how to breathe deeply until the nausea subsides.
A. Administer the prescribed antiemetic medication. Rationale: An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Providing some dry crackers for the client to eat, explaining that this is expected after surgery, and teaching how to breathe deeply until the nausea subsides are unsafe; vomiting increases intraocular pressure, and aggressive intervention is required
Which priority nursing intervention would the nurse implement for a client on diuretic therapy who has developed metabolic alkalosis? A. Fall prevention measures B. Monitoring electrolytes C. Administering antiemetics D. Adjusting the diuretic therapy
A. Fall prevention measures Rationale: A client with alkalosis has hypotension and muscle weakness, which increases the risk for injury due to falls; therefore, to prevent injury, the priority nursing care is to prevent falls. Monitoring electrolytes daily until they return to normal is not the priority nursing care. Antiemetics are prescribed for vomiting and are given low priority. Once the client is protected from the risk for injury, diuretic therapy is adjusted.
Which manifestation would the nurse include when teaching a client about ketoacidosis? (SATA) A. Confusion B. Hyperactivity C. Excessive thirst D. Fruity-scented breath E. Decreased urinary output
A. Confusion C. Excessive thirst D. Fruity-scented breath Rationale: Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include confusion, excessive thirst, fruity-scented breath, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, and shortness of breath. Weakness or fatigue, not hyperactivity, is a symptom. Frequent urination, not decreased urination, is a symptom
Which assessment finding would the nurse associate with a client with diabetic ketoacidosis? (SATA) A. Diaphoresis B. Retinopathy C. Acetone breath D. Increased arterial bicarbonate level E. Decreased arterial carbon dioxide level
A. Diaphoresis C. Acetone breath E. Decreased arterial carbon dioxide level Rationale: A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis. Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a decreased arterial carbon dioxide level. As the glucose level decreases in hypoglycemia, the sympathetic nervous system is activated, and epinephrine and norepinephrine are secreted, causing diaphoresis. Retinopathy is a long-term complication of diabetes caused by microvascular changes in the retina; it is not a sign of ketoacidosis. With ketoacidosis, the serum bicarbonate level is decreased, not increased, in an effort to neutralize ketones when seeking acid-base balance.
A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. Which nursing action is most important when caring for this client? A. Turning the client onto the side B. Measuring the amount of vomitus C. Assessing the wound for dehiscence D. Administering the prescribed antiemetic to the client
A. Turning the client onto the side Rationale: The side-lying position promotes drainage of emesis and secretions from the mouth, reducing the risk of aspiration. Although accurate assessment of intake and output is important, prevention of aspiration is the priority. Dehiscence is not probable at this time; it is more common 5 to 7 days after surgery. Although the antiemetic may prevent additional vomiting, the nurse's priority is to prevent aspiration.
Which information would the nurse include in response to a client's questioning a protein-restricted dietary change required for acute kidney injury? A. "A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses." B. "Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis." C. "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." D. "Currently, your body is unable to synthesize amino acids, so the nitrogen for amino acid synthesis must come from the dietary protein."
C. "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." Rationale: The amount of protein permitted in the diet depends on the extent of kidney function; excess protein causes an increase in urea concentration, excess metabolic waste, and added stress on the kidneys. The restricted protein diet prevents overburdening the client's kidneys at this time. When experiencing acute kidney injury, the kidneys are unable to eliminate the waste products of a high-protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids.
Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation? A. Metabolic alkalosis caused by excessive production of acid metabolites B. Respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide C. Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid D. Metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation
C. Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid Rationale: The restricted ventilation accompanying an asthma attack limits the body's ability to blow off carbon dioxide. As carbon dioxide accumulates in the body fluids, it reacts with water to produce carbonic acid; the result is respiratory acidosis. The problem basic to asthma is respiratory, not metabolic. Respiratory alkalosis is caused by the exhalation of large amounts of carbon dioxide; asthma attacks cause carbon dioxide retention. Asthma is a respiratory problem, not a metabolic one; metabolic acidosis can result from an increase of nonvolatile acids or from a loss of base bicarbonate.
A client has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem would the nurse monitor the client? A. Infection B. Vomiting C. Osteomyelitis D. Bronchospasm
B. Vomiting Rationale: Vomiting may result in aspiration of vomitus because it cannot be expelled; this may cause pneumonia or asphyxia. Infection, osteomyelitis, and bronchospasm generally are not life-threatening problems.
For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes? A. Skeletal and nervous B. Circulatory and urinary C. Respiratory and urinary D. Muscular and endocrine
C. Respiratory and urinary Rationale: Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps adjust the body's pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.
The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? A. The partial pressure of oxygen (PO 2) value is 80 mm Hg. B. The partial pressure of carbon dioxide (PCO 2) value is 60 mm Hg. C. The bicarbonate (HCO 3) value is 50 mEq/L (50 mmol/L). D. Serum potassium value is 4 mEq/L (4 mmol/L).
C. The bicarbonate (HCO 3) value is 50 mEq/L (50 mmol/L). Rationale: The HCO 3 value is elevated. The urinary system compensates by retaining hydrogen (H ) ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO 3 value is 21 to 28 mEq/L (21-28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO 2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO 2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis the PCO 2 level may be increased, it is the increased HCO 3 level that indicates compensation. A potassium (K ) level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5-5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.
A child with type 1 diabetes is admitted to the hospital with deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. Which laboratory findings are the nurse most likely to observe? A. pH 7.25; glucose 60 mg/dL (3.3 mmol/L) B. pH 7.50; glucose 60 mg/dL (3.3 mmol/L) C. pH 7.25; glucose 460 mg/dL (25.5 mmol/L) D. pH 7.50; glucose 460 mg/dL (25.5 mmol/L)
C. pH 7.25; glucose 460 mg/dL (25.5 mmol/L) Rationale: The clinical manifestations indicate ketoacidosis, so these values are expected; the pH of 7.25 indicates acidosis (metabolic or ketoacidosis), and the blood glucose level of 460 mg/dL (25.5 mmol/L), higher than the expected range of 70 to 105 mg/dL (3.9-5.8 mmol/L), indicates severe hyperglycemia. Although the blood pH of 7.25 indicates acidosis, the blood glucose level of 60 mg/dL (3.3 mmol/L) is below the expected range of 70 to 105 mg/dL (3.9-5.8 mmol/L); with ketoacidosis, the child will be hyperglycemic. Both the pH of 7.50 and the glucose level of 60 mg/dL (3.3 mmol/L) are unexpected with ketoacidosis; with ketoacidosis, the pH is decreased and the blood glucose level is increased. Although the blood glucose level is increased with ketoacidosis, the pH is decreased, not increased; a pH of 7.50 indicates alkalosis.
A critically ill 5-year-old child exhibits Kussmaul respirations. Which response would the nurse suspect may be causing an increasing acidbase imbalance? A. Metabolic alkalosis caused by an increase in base bicarbonate B. Respiratory alkalosis caused by excess carbon dioxide (CO2) output C. Respiratory acidosis caused by an accumulation of CO2 D. Metabolic acidosis caused by a concentration of cations in body fluids
D. Metabolic acidosis caused by a concentration of cations in body fluids Rationale: Metabolic acidosis results from an excess concentration of hydrogen cations. The kidneys cannot convert ammonium to ammonia, and there is inadequate base bicarbonate to maintain an appropriate acid-base balance. With Kussmaul respirations there is an excess of hydrogen ions, the opposite of an excess of base bicarbonate. Carbonic acid blown off as CO2 is a compensatory mechanism to counter the present metabolic acidosis. There is an excess of hydrogen ions from a metabolic problem rather than an excess of carbonic acid resulting from retained CO2
