Nokea
The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?
- A. A blood pressure elevation upon activity
- B. A drop in systolic blood pressure $(15 \mathrm{~mm} \mathrm{Hg}$ ) upon rising
- C. A pulsating headache
- D. A drop in diastolic blood pressure $(25 \mathrm{mmHg}$ ) upon rising
Correct Answer: B
Rationale: Postural hypotension occurs when the client rises from a supine or semi- Fowler's position to a standing position and the systolic blood pressure drops by $15 \mathrm{~mm} \mathrm{Hg}$. The client has symptoms of dizziness or a near syncopal episode.
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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.
Upon shift report, the nurse states the following laboratory values: $\mathrm{pH}, 7.44 ; \mathrm{PCO}_2, 30 \mathrm{mmHg}$; and $\mathrm{HCO}_3, 21 \mathrm{mEq} / \mathrm{L}$ for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?
- A. Compensated respiratory alkalosis
- B. Uncompensated respiratory alkalosis
- C. Compensated metabolic acidosis
- D. Compensated metabolic alkalosis
Correct Answer: A
Rationale: The question states that the client has a history of acid-base disturbance. The nurse would first note that the $\mathrm{pH}$ has returned to close to normal indicating compensation. The nurse then assess the $\mathrm{PCO}_2$ (normal: 35 to $45 \mathrm{~mm} \mathrm{Hg}$ ) and $\mathrm{HCO}_3$ (normal: 22 to $27 \mathrm{mEq} / \mathrm{L}$ ) levels. In a respiratory condition, the $\mathrm{pH}$ and the $\mathrm{PCO}_2$ move in opposite directions; thus, the $\mathrm{pH}$ rises and the $\mathrm{PCO}_2$ drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the $\mathrm{pH}$ and the bicarbonate move in the same direction; if the $\mathrm{pH}$ is low, the bicarbonate level will be low, also. In this client, the $\mathrm{pH}$ is at the high end of normal, indicating compensation and alkalosis. The $\mathrm{PCO}_2$ is low, indicating a respiratory condition (opposite direction of the $\mathrm{pH}$ ).
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.
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status?
- A. vital signs
- B. edema
- C. intake and output
- D. weight
Correct Answer: D
Rationale: Daily weight provides the ability to monitor fluid status. A 2-lb $(0.9 \mathrm{kg})$ weight gain in 24 hours indicates that the client is retaining $1 \mathrm{~L}$ of fluid. Also, the loss of weight can indicate a decrease in edema. Vital signs do not always reflect fluid status. Edema could represent a shift of fluid within body spaces and not a change in weight. Intake and output do not account for unexplainable fluid loss.
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.