Nokea
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaCO2 30 mm Hg, PaO2 80 mm Hg, and HCO3- 18 mEq/L. Which assessment should the nurse perform first?
- A. Cardiac rate and rhythm
- B. Skin and mucous membrane assessment
- C. Central nervous system function
- D. Musculoskeletal strength
Correct Answer: A
Rationale: Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As acidosis worsens, the heart rate increases and electrocardiographic changes may be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now.
You may also like to solve these questions
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.5, PaCO2 30 mm Hg, PaO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism?
- A. Increased rate and depth of respirations
- B. Increased urinary output
- C. Increased thirst and hunger
- D. Increased release of acids from the kidneys
Correct Answer: A
Rationale: This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.
A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.52, PaCO2 28 mm Hg, PaO2 90 mm Hg, and HCO3- 22 mEq/L. Which intervention should the nurse implement?
- A. Administer supplemental oxygen
- B. Encourage the client to breathe into a paper bag
- C. Monitor arterial blood gas values every hour
- D. Prepare to administer sodium bicarbonate
Correct Answer: B
Rationale: The client's arterial blood gas values indicate respiratory alkalosis due to hyperventilation, as evidenced by the high pH and low PaCO2. Encouraging the client to breathe into a paper bag helps rebreathing of carbon dioxide, which can correct the alkalosis by increasing PaCO2 levels. Supplemental oxygen is unnecessary as PaO2 is normal. Monitoring arterial blood gases every hour is not the priority intervention, and sodium bicarbonate would worsen alkalosis.
A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 48 mm Hg, and HCO3- 24 mEq/L. What should the nurse identify as the underlying pathophysiology?
- A. Respiratory acidosis due to inadequate gas exchange
- B. Metabolic acidosis due to excess acid production
- C. Respiratory alkalosis due to hyperventilation
- D. Metabolic alkalosis due to bicarbonate retention
Correct Answer: B
Rationale: Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that this client has respiratory acidosis indicates an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
- A. Monitor daily hemoglobin and hematocrit values
- B. Administer furosemide (Lasix) intravenously
- C. Encourage the client to take deep breaths
- D. Teach the client fall prevention measures
Correct Answer: D
Rationale: The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Which manifestations should the nurse assess for this acid-base imbalance?
- A. Positive Chvostek's sign
- B. Elevated blood pressure
- C. Bradycardia
- D. Increased muscle strength
- E. Anxiety and irritability
Correct Answer: A,E
Rationale: A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic alkalosis include positive Chvostek's sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, and anxiety and irritability.