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What should the nurse focus on when creating a nursing care plan for a patient with metabolic acidosis?
- A. Frequent periods of ambulation
- B. Increasing fluid intake
- C. Decreasing fluid intake
- D. Deep-breathing exercises
Correct Answer: D
Rationale: Deep breathing will cause the patient to blow off CO2 and assist in increasing the pH and reduce the acidity.
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A patient admitted in a state of extreme anxiety has vital signs of T 98.6°F (37°C) P 81 BP 130/86 R 32. What will result if this hyperventilation continues?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: Respiratory alkalosis is caused by hyperventilation as the lungs blow off large amounts of CO2.
What is the nurse closely assessing for in a patient with hypokalemia?
- A. Systemic edema
- B. Cardiac complications
- C. Muscle cramping
- D. Impaired kidney function
Correct Answer: B
Rationale: Hypokalemia can affect cardiac function.
The nurse explains to a patient that the drug Lasix reduces edema by drawing water from the interstitial space into the intravascular space. What is this process called?
- A. Diffusion
- B. Filtration
- C. Osmosis
- D. Homeostasis
Correct Answer: C
Rationale: Osmosis is the movement of water from an area of lower concentration to an area of higher concentration.
The nurse modifies the care plan for the immobilized patient after assessing a calcium level of 6.2 mEq/L. What nursing assessment should the nurse include when modifying this care plan?
- A. Osteoporosis
- B. Tooth loss
- C. Renal calculi
- D. Contractures
Correct Answer: C
Rationale: Hypercalcemia occurs when calcium levels exceed 5.8 mEq/L. It may occur when calcium stored in the bone enters the circulation for example, in patients who are immobilized. Renal calculi may develop because of high levels of calcium.
A child has been having an asthma attack for the last 8 hours. Because of the child's inability to exhale effectively the nurse assesses for respiratory __.
Correct Answer: acidosis
Rationale: Retained CO2 will lead to respiratory acidosis.