Nokea
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.
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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 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 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 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 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.