SDL 2 - Acid Base Balance
The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38 (7.38), Paco2 of 38 mm Hg (38 mm Hg), Pao2 of 86 mm Hg (86 mm Hg), and HCO3 of 23 mEq/L (23 mmol/L). What action should the nurse take in response to these results? Discontinue the oxygen. Continue monitoring the client. Call 911 to have the client intubated immediately. Have another set drawn because these results are not possible.
Continue monitoring the client. Rationale: The client's results fall in the normal range for pH (7.35 to 7.45), Paco2 (35 to 45 mm Hg), and bicarbonate level (21 to 28 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis were present.
A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status should avoid which action? Keeping the head of the bed elevated Monitoring the flow rate of supplemental oxygen Assisting the client to turn, cough, and breathe deeply Encouraging the client to breathe slowly and shallowly
Encouraging the client to breathe slowly and shallowly Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.
The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH? Fall Rise Double Remain unchanged
Fall Rationale: CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.
14.A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. Seizures Lethargy Headache Weakness Confusion Hyperactivity
Lethargy Headache Weakness Confusion Rationale: In both respiratory and metabolic acidosis, the central nervous system (CNS) is depressed. Headache, lethargy, weakness, and confusion develop, leading eventually to coma and death. Therefore, seizures and hyperactivity would not be noted.
18.An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? Headache and tachypnea Hyperactivity and dyspnea Muscle twitches and cyanosis Lightheadedness and paresthesias
Lightheadedness and paresthesias Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. The remaining three options are not clinical manifestations of respiratory alkalosis.
30.The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder? "Do you have shallow breathing?" "Do you feel like you have a lot of energy?" "Do you have a headache or become confused?" "Do you feel dizzy or have tingling sensations?"
"Do you have a headache or become confused?" Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, along with hyperkalemia, a rapid irregular pulse, and dysrhythmias.
A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation? "Blood is drawn from the ulnar artery." "I know I have to lie down while blood is drawn." "This test is done to ensure adequate collateral circulation." "Direct pressure has to be placed over the site for 15 minutes after blood is drawn."
"This test is done to ensure adequate collateral circulation." Rationale: The Allen test is important because it ensures collateral circulation to the hand if thrombosis of the radial artery occurs after the puncture. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options 1, 2, and 4 are incorrect.
The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen test on the client. The nurse would perform the steps in which order to conduct an Allen test? Arrange the actions in the order that they should be performed. All options must be used. 1. Apply pressure over the ulnar and radial arteries. 2. Release pressure from the ulnar artery. 3. Explain the procedure to the client. 4. Document the findings. 5. Ask the client to open and close the hand repeatedly. 6. Assess the color of the extremity distal to the pressure point.
3, 1, 5, 2, 6, 4 3. Explain the procedure to the client. 1. Apply pressure over the ulnar and radial arteries. 5. Ask the client to open and close the hand repeatedly. 2. Release pressure from the ulnar artery. 6. Assess the color of the extremity distal to the pressure point. 4. Document the findings. Rationale: The Allen test is performed before an arterial blood gas specimen is obtained from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse would first explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while continuing to compress the radial artery and then assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings.
A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because... Potassium is returned to extracellular fluid when metabolic acidosis is corrected. Hyperkalemia causes an alkalosis that results in potassium being shifted into the cells. Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells. In alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate.
Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells. Rationale: Changes in pH (hydrogen ion concentration) will affect potassium balance. In acidosis, hydrogen ions accumulate in the intracellular fluid (ICF), and potassium shifts out of the cell to the extracellular fluid to maintain a balance of cations across the cell membrane. In alkalosis, ICF levels of hydrogen diminish, and potassium shifts into the cell. If a deficit of H+ occurs in the extracellular fluid, potassium will shift into the cell. Acidosis is associated with hyperkalemia, and alkalosis is associated with hypokalemia.
A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem? Administer prescribed antibiotics. Have the client breathe into a paper bag. Administer antipyretics as needed (on prn basis). Request a prescription for a partial rebreather oxygen mask.
Administer prescribed antibiotics. Rationale: The most effective way to treat an acid-base disorder is to treat the underlying cause of the disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base balance. The paper bag and partial rebreather mask will assist the client in rebreathing exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? A decreased pH and an increased PaCO2 An increased pH and a decreased PaCO2 A decreased pH and a decreased HCO3- An increased pH and an increased HCO3-
An increased pH and an increased HCO3- Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition. Note: {The original problem is metabolic alkalosis due to prolonged vomiting, therefore pH is increased and bicarb is increased. The respiratory system is trying to compensate by respiratory acidosis (hypoventilation to decrease the pH, moving it towards acidotic side). Because the original problem is metabolic acidosis, the answer is elevated pH and bicarb}.
19.The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention? Perform the Allen's test. Apply a warm compress. Administer the antidote for heparin. Notify the hospital laboratory supervisor.
Apply a warm compress. Rationale: The application of a warm compress enhances the absorption of blood in the hematoma. Allen's test is performed before the collection of the specimen to assess collateral blood flow. Heparinized syringes are used for the collection of an arterial blood gas, but no heparin is administered to a client. The antidote for heparin is not administered at this time unless prescribed. The laboratory department is not responsible for collecting the arterial blood gas specimen. Additionally, there is no useful reason to notify the hospital laboratory supervisor.
24.The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn? Holding a warm compress over the puncture site for 5 minutes Encouraging the client to open and close the hand rapidly for 2 minutes Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Rationale: Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.
Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B. Assess the client for pain and administer pain medication as prescribed. C. Encourage the client to take short shallow breaths for 5 minutes. D. Prepare to administer sodium bicarbonate IV over 30 minutes.
B. Assess the client for pain and administer pain medication as prescribed. Rationale: These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.
The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. What is the purpose of this type of respiration? Select all that apply. Correct bradypnea Blow off carbon dioxide Correct metabolic acidosis Correct an acid-base imbalance Cause respiratory compensation Stimulate Cheyne-Stokes respirations
Blow off carbon dioxide Correct metabolic acidosis Correct an acid-base imbalance Cause respiratory compensation Rationale: Abnormally deep, regular, and increased in rate respirations enable respiratory compensation in an effort to help correct metabolic acidosis. These respirations are called Kussmaul's respirations, and they occur by exhaling excess carbon dioxide. Bradypnea is abnormally slow but regular respirations. Cheyne-Stokes respirations have rhythmic crescendo and decrescendo of rate and depth, including brief periods of apnea. Kussmaul's respirations do not stimulate Cheyne-Stokes respirations.
A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client should expect to note which signs/symptoms? Disorientation and dyspnea Decreased respiratory rate and depth Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias
Decreased respiratory rate and depth Rationale: A client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism. A client with metabolic acidosis would display the symptoms noted in option 3. The client with respiratory acidosis and alkalosis would display the symptoms noted in options 1 and 4, respectively. {Note: When you have a metabolic problem (acidosis or alkalosis), any respiratory symptom is related to the compensation. For example, if you have (like in this question) metabolic alkalosis, then any respiratory symptom will be of respiratory acidosis → hypoventilation, thus decreased respiratory rate and depth. Yet, if in the question you have metabolic acidosis, then any respiratory symptom with be that of respiratory alkalosis → hyperventilation, thus increased respiratory rate and depth}.
The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the health care provider about these levels, the nurse should anticipate receiving from the HCP which prescription for this client? Obtain a serum alcohol level. Obtain a serum salicylate level. Discontinue nasogastric suctioning. Discontinue the client's fentanyl patch.
Discontinue nasogastric suctioning. Rationale: The arterial blood gas (ABG) results indicate metabolic alkalosis, as the pH and bicarbonate are elevated. Nasogastric suctioning may cause metabolic alkalosis by decreasing the acid components in the stomach. Excess alcohol ingestion and salicylate toxicity may cause metabolic acidosis. Fentanyl (an opioid) may cause respiratory acidosis.
45.The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance? Disorientation and dyspnea Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias Decreased respiratory rate and depth, cardiac irregularities
Drowsiness, headache, and tachypnea Rationale: The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. However, by 24 hours post overdose, the compensatory mechanism fails, and the client reverts to metabolic acidosis. The client with metabolic alkalosis (option 4) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. Options 1 and 3 indicate respiratory acidosis and alkalosis, respectively.
A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms indicating the acid-base disturbance that could occur in the client? Bradypnea, dizziness, and paresthesias Headache, nausea, vomiting, and diarrhea Bradycardia, listlessness, and hyperactivity Restlessness, confusion, and a positive Trousseau's sign
Headache, nausea, vomiting, and diarrhea Rationale: The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours after the poisoning. If metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity-smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. Shortly after aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours postoverdose, however, the compensatory mechanism fails, and the client reverts to metabolic acidosis.
12.A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? Bradycardia and hyperactivity Decreased respiratory rate and depth Headache, restlessness, and confusion Bradypnea, dizziness, and paresthesias
Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.
A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance? Hypokalemia Hypercalcemia Hypochloremia Hypernatremia
Hypokalemia Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.
21.A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care knowing that what reaction is the most powerful regulator of acid-base balance? Buffer Kidney Cations Respiratory
Kidney Rationale: The renal reaction is the most powerful regulator of acid-base balance. Renal tubules secrete hydrogen ions and potassium effectively, and in lesser amounts they secrete ammonia and uric acid. They respond to large or chronic fluctuations in hydrogen ion production or elimination and also reabsorb carbon dioxide molecules. However, the kidney tubules have the slowest response (hours to days).
A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis. The acid-base disorders in the remaining options are not likely to occur in diabetes mellitus unless there is another existing disorder.
A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care knowing that the client is at risk for the development of which type of acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, potentially leading to the condition known as diabetic ketoacidosis. The remaining options are incorrect.
The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul respirations. The nurse knows that the purpose of this type of breathing is to correct what imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis Rationale: Kussmaul respirations cause respiratory compensation in an attempt to correct metabolic acidosis by exhaling carbon dioxide. This breathing pattern is very deep and rapid and is the respiratory system's attempt to correct metabolic acidosis by exhaling carbon dioxide.
The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.
A patient has the following ABG results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. When assessing the pt, the nurse would expect the patient to have Muscle cramping Warm, flushed skin Respiratory rate of 36 Blood pressure of 94/52
Muscle cramping Rationale: The patient is experiencing metabolic alkalosis (elevated pH and elevated HCO3). Clinical manifestations of metabolic alkalosis include hypertonic muscles and cramping and reduced respiratory rate. Hypotension and warm, flushed skin may occur with respiratory acidosis.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. Nausea Confusion Bradypnea Tachycardia Hyperkalemia Lightheadedness
Nausea Confusion Tachycardia Lightheadedness Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.
A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis? Sodium Potassium Magnesium Phosphorus
Potassium Rationale: The serum potassium level tends to rise with metabolic acidosis. This is because potassium moves out of the cells and into the bloodstream. When acidosis is corrected with treatment, the potassium will shift back into the cellular compartment. This can cause a rapid drop in the serum potassium level. Because of the effects of potassium on the heart, this electrolyte should be monitored closely while the client is treated.
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? Sodium level of 145 mEq/L (145 mmol/L) Potassium level of 3.0 mEq/L (3.0 mmol/L) Magnesium level of 1.3 mEq/L (0.65 mmol/L) Phosphorus level of 3.0 mg/dL (0.97 mmol/L)
Potassium level of 3.0 mEq/L (3.0 mmol/L) Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.
The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note? Sodium level of 145 mEq/L (145 mmol/L) Potassium level of 5.2 mEq/L (5.2 mmol/L) Phosphorus level of 3.0 mg/dL (0.97 mmol/L) Magnesium level of 1.3 mg/dL (0.53 mmol/L)
Potassium level of 5.2 mEq/L (5.2 mmol/L) Rationale: Interpretation of the arterial blood gas (ABG) indicates metabolic acidosis with partial compensation by the respiratory system. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur.
An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder? Put the client in a supine position. Provide emotional support and reassurance. Withhold all sedative or antianxiety medications. Tell the client to breathe very deeply but more slowly.
Provide emotional support and reassurance. Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client should try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.
20.A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. Change the nasal cannula to a shovel face mask; then have the ABG samples drawn. Leave the nasal cannula in place for 15 minutes; then have the ABG samples drawn. Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn.
Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. Rationale: The client should have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore, the remaining options are incorrect.
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. Respirations that are shallow Respirations that are increased in rate Respirations that are abnormally slow Respirations that are abnormally deep Respirations that cease for several seconds
Respirations that are increased in rate Respirations that are abnormally deep Rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.
The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore, the remaining options are incorrect.
15.The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Rationale: In respiratory acidosis, the pH is decreased and the Paco2 level is increased. Options 1, 2, and 4 are incorrect. In respiratory alkalosis, the pH is elevated with a decrease in Paco2. In metabolic acidosis, both the pH and the HCO3 are decreased. In metabolic alkalosis, the pH and HCO3 are increased.
11. The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.
The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30 (7.30), a Paco2 of 58 mm Hg (58 mm Hg), a Pao2 of 80 mm Hg (80 mm Hg), and an HCO3 of 26 mEq/L (26 mmol/L). The nurse should interpret this to mean that the client has which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Paco2 is elevated. In respiratory alkalosis, an opposite effect occurs; the pH is elevated and the Paco2 is low. In metabolic acidosis, the pH is low and the bicarbonate is low; in metabolic alkalosis, the opposite effect occurs.
10.The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? Respiratory acidosis from inadequate ventilation Respiratory alkalosis from anxiety and hyperventilation Metabolic acidosis from calcium loss due to broken bones Metabolic alkalosis from taking analgesics containing base products
Respiratory acidosis from inadequate ventilation Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? Metabolic acidosis with compensation Respiratory acidosis with compensation Metabolic acidosis without compensation Respiratory acidosis without compensation
Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm). In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3-) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.
The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition? Metabolic acidosis, compensated Respiratory alkalosis, compensated Metabolic alkalosis, uncompensated Respiratory acidosis, uncompensated
Respiratory acidosis, uncompensated Rationale: Normal pH is 7.35 to 7.45. In a respiratory condition, the pH and the Paco2 will exhibit opposite effects; in this case, the pH is low and the Paco2 is increased. In an acidotic condition, the pH is decreased. Therefore, the values identified in the question indicate a respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not within the normal range, the condition is uncompensated.
Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. The normal Paco2is 35 to 45 mm Hg, and the normal HCO3concentration is 21 to 28 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In a metabolic condition, the pH and the bicarbonate move in the same direction.
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? Metabolic acidosis, compensated Respiratory alkalosis, compensated Metabolic alkalosis, uncompensated Respiratory acidosis, uncompensated
Respiratory alkalosis, compensated Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.
The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse should interpret these values as an indication of which condition? Metabolic acidosis, uncompensated Respiratory acidosis, uncompensated Respiratory alkalosis, uncompensated Metabolic acidosis, partially compensated
Respiratory alkalosis, uncompensated Rationale: In respiratory alkalosis, the pH will be higher than normal, and the Paco2 will be low. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. The correct option is the only one that reflects these conditions.
44.The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution? Contact isolation Seizure precautions Bleeding precautions Neutropenic precautions
Seizure precautions Rationale: The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. The remaining options are unnecessary in the care of the client experiencing metabolic alkalosis.
The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extra-pulmonary causes can lead to respiratory failure? Select all that apply. Stroke Pneumonia Sleep apnea Myasthenia gravis Obstructive lung disease Opioid analgesics, sedatives, anesthetics
Stroke Sleep apnea Myasthenia gravis Opioid analgesics, sedatives, anesthetics Rationale: Extrapulmonary causes of respiratory failure include the following: stroke, sleep apnea, myasthenia gravis, and opioid analgesics, sedatives, and anesthetics. Both obstructive lung disease and pneumonia are intrapulmonary causes of respiratory failure.
The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply. Tetany Lethargy Tingling Confusion Numbness Restlessness
Tetany Tingling Confusion Numbness Restlessness Rationale: A client's reaction to alkalosis causes tingling and numbness of the fingers, restlessness, and tetany caused by irritability of the central nervous system (CNS) results. If the severity of alkalosis increases, convulsions and coma may occur. {Note: Confusion is a symptom of alkalosis (both respiratory alkalosis and metabolic alkalosis; Saunders did NOT include CONFUSION as one of the correct answers, but it is CORRECT}.
The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? The client has acidotic blood. The client is probably overreacting. The client is fluid volume overloaded. The client is probably hyperventilating.
The client is probably hyperventilating. Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclusion can be made about a client's fluid volume status from the information provided.
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? pH 7.25, Paco2 50 mm Hg (50 mm Hg) pH 7.35, Paco2 40 mm Hg (40 mm Hg) pH 7.50, Paco2 52 mm Hg (52 mm Hg) pH 7.52, Paco2 28 mm Hg (28 mm Hg)
pH 7.25, Paco2 50 mm Hg (50 mm Hg) Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.
The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply. Buffer Cardiac Nervous Chemical Respiratory Neuromuscular
Cardiac Nervous Neuromuscular Rationale: Most problems of alkalosis are related to increased stimulation of the cardiac, nervous, and neuromuscular systems. Chemical reactions are also called buffer systems and are not related to most problems of alkalosis. The respiratory system is related to respiratory alkalosis and not metabolic alkalosis.
