Nokea
The emergency department (ED) nurse is caring for a client with a possible acid- base imbalance. The physician has prescribed an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?
- A. $\mathrm{PaO}_2$
- B. $\mathrm{PO}_2$
- C. Carbonic acid
- D. Bicarbonate
Correct Answer: D
Rationale: Arterial blood gas (ABG) results are the main tool for measuring blood $\mathrm{pH}, \mathrm{CO}_2$ content $\left(\mathrm{PaCO}_2\right)$, and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. $\mathrm{PaO}_2$ and $\mathrm{PO}_2$ are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
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The nurse is reviewing lab work on a newly admitted client. Which diagnostic stud(ies) confirms the nursing problem statement of dehydration? Select all that apply.
- A. An elevated hematocrit level
- B. A low urine specific gravity
- C. Electrolyte imbalance
- D. Low protein level in the urine
- E. Absence of ketones in urine
Correct Answer: A,C
Rationale: Dehydration is a common primary or secondary diagnosis in health care. An elevated hematocrit level reflects low fluid level and a hemoconcentration. Electrolytes are in an imbalance as sodium and potassium levels are excreted together in client with dehydration. The urine specific gravity, due to concentrated particle level, is high. Protein is not a common sign of dehydration. Ketones are always present in the urine.
The client's lab values are sodium $166 \mathrm{mEq} / \mathrm{L}$, potassium $5.0 \mathrm{mEq} / \mathrm{L}$, chloride $115 \mathrm{mEq} / \mathrm{L}$, and bicarbonate $35 \mathrm{mEq} / \mathrm{L}$. What condition is this client likely to have, judging by anion gap?
- A. Metabolic acidosis
- B. Respiratory alkalosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: A
Rationale: The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds $16 \mathrm{mEq} / \mathrm{L}$ indicates metabolic acidosis. In this case, the anion gap is $(166+5)-(115+35)$, yielding $21 \mathrm{mEq} / \mathrm{L}$, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?
- A. Abnormal potassium level
- B. Elevated hematocrit level
- C. Low white blood count
- D. Low urine specific gravity
Correct Answer: B
Rationale: When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also noted. Other causes of an abnormal potassium level may be present.
The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?
- A. Decreased abdominal girth
- B. Increased level of consciousness
- C. Weight maintenance
- D. Pulse rate decrease
Correct Answer: A
Rationale: Third-spacing is the translocation of fluid from the intravascular to intercellular space to tissue compartment. Anasarca is the general edema in the organ cavities such as the abdomen. Monitoring the abdominal girth provides data on the localization of the fluid in the interstitial space. A decrease in girth, in particular, notes improvement. Level of consciousness is not affected unless shock occurs. Weight remains the same as there is a shifting in fluid; pulse rate could fluctuate according to fluid movement.
A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?
- A. Slow heart rate
- B. Kidney stones and blood clots
- C. Imbalance in electrolytes
- D. Elevated central venous pressure (CVP)
Correct Answer: B
Rationale: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below $4 \mathrm{~cm} \mathrm{H}_2 \mathrm{O}$.