test 2 med surg

Discontinue or decrease the oxygen flow rate

A client admitted with a history of emphysema and a diagnosis of acute respiratory failure with respiratory acidosis has oxygen at 3 L/min nasal cannula. Four hours after admission, the client exhibits increased restlessness and confusion followed by a decreased respiratory rate and lethargy. Which intervention would the nurse implement at this time?

metabolic alkalosis

A client is hospitalized after 4 days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, pCO2 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?

electrolyte imbalance

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. A diagnosis of gastric ulcer is made. Which is the primary nursing concern?

global brain dysfunction and is characterized by a waxing and waning of breathing with periods of apnea.

Cheyne-Stokes breathing occurs with

440

During an 8-hour shift, a client has a 6-oz (180-mL) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous (IV) fluids equaled the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record?

dysrhythmias and death

Fluid lost through vomiting can produce inadequate fluid volume and electrolyte imbalance, which can lead to

an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide.

Kussmaul breathing is an

the regular, rapid, and deep respirations observed in clients who have metabolic acidosis.

Kussmaul respirations are

hyperkalemia

Severe bradycardia and slowing of the cardiac conduction system are the most severe complications of

metabolic alkalosis

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco2 of 45 mm Hg, HCO3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support which diagnosis?

The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L).

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?

encourage deep breathing

When a client who has had a thoracotomy develops respiratory acidosis, which action would the nurse take?

check blood return

When a client who is receiving a potassium infusion via a peripheral intravenous (IV) site reports a burning sensation above the IV site, which action would the nurse take first?

cantaloupe

When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest?

An elevated pH, decreased PCO2

When the nurse is reviewing a client's arterial blood gas results, which finding is consistent with respiratory alkalosis?

A trended urinary output of at least 30 mL/h

Which clinical manifestation would the nurse associate with successful fluid replacement therapy?

restlessness, headache, irritability

Which early signs of respiratory acidosis would the nurse expect the client with a restrictive airway disease to exhibit?

Monitor for cardiac dysrhythmias.

Which nursing action is the priority for a client who has a serum potassium level of 6.7 mEq/L (6.7 mmol/L)?

inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate

Which statement explains why metabolic acidosis develops with kidney failure?

metabolic acidosis

kussmaul resp. findings indicate possible ...

fever, hypoxemia, and restrictive lung disease.

tachypnea which is a sign of