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A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestations of this acid-base imbalance should the nurse assess?
- A. Agitation
- B. Kussmaul respirations
- C. Seizures
- D. Positive Chvostek's sign
Correct Answer: B
Rationale: The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek's sign are manifestations of the electrolyte imbalances that accompany alkalosis.
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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 assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: D
Rationale: Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin, resulting in 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.
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.
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.