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The nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing respiratory acidosis. The client asks what is making the acidotic state. What does the nurse identify as the result of the disease process that causes the fall in $\mathrm{pH}$ ?
- A. The lungs are unable to breathe in sufficient oxygen.
- B. The lungs are unable to exchange oxygen and carbon dioxide.
- C. The lungs have ineffective cilia from years of smoking.
- D. The lungs are not able to regulate carbonic acid levels.
Correct Answer: D
Rationale: In clients with chronic respiratory acidosis, the client's lungs are not able to regulate carbonic acid levels. The increase in carbonic acid leads to acidosis. In COPD, the client is able to breathe in oxygen, and gas exchange can occur, but the lungs' ability to remove the carbon dioxide from the system is limited. Although individuals with COPD frequently have a history of smoking, ineffective cilia is not the cause of the acidosis.
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The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?
- A. Cool and pale skin
- B. Crackles in the lung fields
- C. Distended jugular veins
- D. Dark, concentrated urine
Correct Answer: D
Rationale: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?
- A. Respiratory alkalosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Metabolic acidosis
Correct Answer: B
Rationale: Metabolic alkalosis results in increased plasma $\mathrm{pH}$ because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate- containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more $\mathrm{CO}_2$ than necessary.
The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage?
- A. A grilled chicken sandwich with mayonnaise
- B. A natural fruit salad with nuts
- C. A hot dog with ketchup
- D. A fresh grilled tuna entr?©e with fresh asparagus
Correct Answer: C
Rationale: Foods high in sodium include processed meats, such as hot dogs and cold cuts; fast foods; frozen meals; cheeses; soups and juices; and salted snack foods to name a few.
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.
A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia?
- A. Hypervolemia
- B. Hypercalcemia
- C. Hypomagnesemia
- D. Hypermagnesemia
Correct Answer: C
Rationale: If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek's sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek's sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.