Chapter 14: Assessment and Care of Patients with Acid-Base Imbalances Nursing School Test Banks

Chapter 14: Assessment and Care of Patients with Acid-Base Imbalances

Test Bank

MULTIPLE CHOICE

1. In a client with less than the normal amount of bicarbonate in the blood and other extracellular fluids, what response does the nurse anticipate?

a.

Increased risk for acidosis

b.

Decreased risk for acidosis

c.

Increased risk for alkalosis

d.

Decreased risk for alkalosis

ANS: A

Bicarbonate (H2CO3) is a weak base with an overall negative charge. When hydrogen ions are present in slight or mild excess (mild acidosis), bicarbonate can buffer or absorb the excess hydrogen ions, reducing the hydrogen ion concentration and bringing the pH back up to normal. If the total body bicarbonate concentration is low, especially in the blood, the action of buffering or absorbing excess hydrogen ions is reduced, and the person is at increased risk for acidosis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 202

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. Which response is an example of compensation for an acid-base imbalance?

a.

Increase in the rate and depth of respirations when exercising

b.

Increased urinary output when blood pressure increases during exercise

c.

Increased thirst when spending time in an excessively dry environment

d.

Increased release of acids from kidneys during exacerbation of chronic obstructive pulmonary disease (COPD)

ANS: A

The respiratory system increases its activity by blowing off excess carbon dioxide. This occurs as a result of the occurrence of lactic acidosis in skeletal muscle, when blood flow and oxygenation are insufficient to meet the increased demand for oxygen (oxygen debt) created during increased skeletal muscle metabolism. The other three options are not compensatory mechanisms for acid-base imbalances.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 200

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. When a client has an arterial blood pH of 7.48, which buffer action will bring the pH back to normal?

a.

Absorption of bicarbonate ions from the blood

b.

Release of bicarbonate ions into the blood

c.

Absorption of hydrogen ions from the blood

d.

Release of hydrogen ions into the blood

ANS: D

Buffers can act as an acid (releasing a hydrogen ion) or as a base (absorbing a hydrogen ion) to assist in keeping the pH and hydrogen ion concentration of body fluids within the normal range. An arterial pH of 7.48 indicates a deficiency of hydrogen ions. This situation would cause buffers to act like acids and release hydrogen ions into the blood.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 200

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

4. A client has moderate acidosis. Which assessment does the nurse perform first?

a.

Take the clients pulse and blood pressure, and analyze the electrocardiogram (ECG) strip.

b.

Assess respiratory rate and depth and work of breathing.

c.

Perform assessments of musculoskeletal strength.

d.

Determine whether the client is awake, alert, and oriented.

ANS: A

Priority assessments for the client with acidosis relate to the cardiovascular system. Acidosis can lead to lethal cardiac dysrhythmias.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

5. In the client with hypoventilation, which change in arterial blood gases does the nurse evaluate to determine whether treatment measures are being effective?

a.

Decreased arterial blood pH

b.

Decreased arterial blood carbon dioxide

c.

Increased arterial blood bicarbonate

d.

Increased arterial blood oxygen

ANS: C

Because kidneys regulate pH by controlling bicarbonate concentration and the lungs regulate pH by controlling carbon dioxide loss, loss of one function can be at least partially compensated for by the other function. When pulmonary function is decreased, so that adequate amounts of carbon dioxide are not excreted, the pH falls, stimulating the kidneys to reabsorb more bicarbonate to balance the increased acid production.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Evaluation)

6. In a client 4 minutes post cardiac arrest, the nurse correlates the largest source of excess hydrogen ions with which cause?

a.

Excess renal retention of carbon dioxide due to hypoxia

b.

Release of intracellular acids due to widespread tissue destruction

c.

Anaerobic metabolism, leading to the buildup of lactic acid

d.

Using fat as a fuel source, resulting in increased fat degradation

ANS: C

Glucose metabolism continues under anaerobic conditions to supply the body with chemical energy (adenosine triphosphate [ATP]). However, this metabolism is incomplete, stopping at lactic acid production instead of continuing into the Krebs cycle. This results in a large buildup of lactic acid, which releases excessive amounts of hydrogen ions into the blood.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 202

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

7. A client has mild acidosis but after a day has not compensated for it. Which action by the nurse is best?

a.

Review the clients daily hemoglobin and hematocrit.

b.

Ask the laboratory to rerun todays arterial blood gases.

c.

Document the finding and notify the physician.

d.

Apply 2 L of oxygen via nasal cannula.

ANS: A

Hemoglobin is part of the buffering system. Low hemoglobin affects acid-base balance by decreasing the bodys ability to compensate for mild acidosis. Rerunning the specimen would take time and might require another sample. The nurse may need to notify the physician but would need more information to report, such as hemoglobin and hematocrit values. Adding 2 liters of oxygen would not help the client as much as he or she would be helped if the cause of the refractory acidosis was determined.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

8. A client has an arterial blood gas pH of 7.48. How does the nurse interpret this clients acid-base status?

a.

An unknown acid-base balance status

b.

A normal blood hydrogen ion concentration

c.

A deficit in blood hydrogen ion concentration

d.

An excess in blood hydrogen ion concentration

ANS: C

The pH is the negative log of the hydrogen ion concentration. The normal pH of arterial blood ranges between 7.35 and 7.45. A pH of 7.48 indicates a decrease in the hydrogen ion concentration (alkalosis).

DIF: Cognitive Level: Knowledge/Remembering REF: p. 198

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Evaluation)

9. The nurse reads in the medical record that a client has Kussmaul respirations. Which assessment finding is consistent with this condition?

a.

Deep, rapid respirations

b.

Respirations with an irregular pattern

c.

Shallow, grunting respirations

d.

Use of accessory muscles when breathing

ANS: A

Kussmaul respirations are described as deep and rapid and are the bodys attempt to compensate for acidosis by blowing off excess H+ in the form of carbon dioxide.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 205

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

10. The nurse monitors for which acid-base imbalance in a client who has hypoxemia?

a.

Reduced carbon dioxide production leading to alkalosis

b.

Reduced carbon dioxide retention leading to alkalosis

c.

Excess carbon dioxide production leading to acidosis

d.

Excess carbon dioxide retention leading to acidosis

ANS: C

Hypoxemia (lower than normal blood oxygen level) causes some organs, tissues, and cells to have anaerobic metabolism. This situation leads to a buildup of carbon dioxide. Elevated levels of carbon dioxide lead to an increase in blood hydrogen ion levels and acidosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications Related to Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

11. A client has been placed on a ventilator. The physician has ordered that the ventilator be set to deliver a respiratory rate set of 28 breaths/min. The nurse questions the order, citing concerns about which acid-base problem?

a.

Acid deficit: alkalosis

b.

Base excess: alkalosis

c.

Acid excess: acidosis

d.

Base deficit: acidosis

ANS: A

A ventilator set at too high a ventilation rate and/or too high a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Evaluation)

12. The nurse monitors for which acid-base problem in a client who is taking furosemide (Lasix) for hypertension?

a.

Acid excess secondary to respiratory acidosis

b.

Acid deficit secondary to respiratory alkalosis

c.

Acid excess secondary to metabolic acidosis

d.

Acid deficit secondary to metabolic alkalosis

ANS: D

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

13. The nurse expects to find renal compensation for an acid-base imbalance in which situation?

a.

Mild to moderate dehydration in a middle-aged client who jogged for 2 hours

b.

Acute asthma attack with wheezing of 6 hours duration in an older man

c.

Food poisoning with vomiting for 12 hours in a middle-aged woman

d.

Hypoxemia for 4 days from pneumonia in an adult woman

ANS: D

Renal compensation (change in excretion or reabsorption of hydrogen ions and bicarbonate ions) for an acid-base imbalance is very potent and requires from many hours up to several days to begin. It does not provide immediate compensation, nor does it respond to acute imbalances. For a person who has been hypoxemic for several days, renal compensation with increased excretion of hydrogen ions and increased reabsorption of bicarbonate would have been initiated.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 201

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

14. A client has moderate metabolic alkalosis. What is the priority intervention for the nurse?

a.

Monitor daily laboratory values.

b.

Assess the clients muscle strength.

c.

Determine the cause of the problem.

d.

Teach the client preventive measures.

ANS: B

Although all options are viable nursing interventions, the priority is providing for client safety. Clients with metabolic alkalosis have muscle weakness and thus are at risk for falling.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

15. A client has acute pancreatitis and a risk for acid-base imbalance. The nurse plans to assess for which manifestation consistent with this condition?

a.

Agitation

b.

Kussmaul respirations

c.

Seizures

d.

Positive Chvosteks sign

ANS: B

The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvosteks sign are manifestations of the electrolyte imbalances that accompany alkalosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

16. The nurse assesses for acidosis in the client with which assessment data?

a.

Serum sodium level of 130 mEq per liter and peripheral edema

b.

Serum sodium level of 144 mEq per liter and tachycardia

c.

Serum potassium level of 6.5 mEq per liter and flaccid paralysis

d.

Serum potassium level of 4.5 mEq per liter and hyperactive deep tendon reflexes

ANS: C

When acidosis is present, the hydrogen ion concentration of the extracellular fluid (ECF) is increased above normal. The physiologic action to reduce the ECF hydrogen ion concentration is to move the hydrogen ions into the cells in exchange for potassium ions, thereby maintaining the electroneutrality of the intracellular fluid. As a result, acidosis is accompanied by hyperkalemia, which diminishes nerve and skeletal muscle excitability, causing flaccid paralysis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

17. The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour ago. What action does the nurse take next?

a.

Assess clients rate, rhythm, and depth of respiration.

b.

Measure the clients pulse and blood pressure.

c.

Document findings and continue to monitor.

d.

Notify the physician as soon as possible.

ANS: A

Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia) but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse needs to have more data to report.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications Related to Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

18. In evaluating the electrocardiogram (ECG) in a client with acidosis, the nurse correlates which ECG change with effectiveness of therapy?

a.

Small U-waves present after each complex

b.

Heart rate decreased to 62 beats/min

c.

T-waves present, normal height

d.

P-wave preceding the QRS complex

ANS: C

Acidosis and accompanying hyperkalemia affect cardiac conduction, inducing tall T-waves, widened QRS complexes, and prolonged PR intervals. When T-waves return to a height of less than 3 mm, acidosis and hyperkalemia are resolving.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Evaluation)

19. A client has the following arterial blood results: pH 7.12, HCO3 22 mEq/L, PCO2 65 mm Hg, PO2 56 mm Hg. The nurse correlates these values with which clinical situation?

a.

Diabetic ketoacidosis in a person with emphysema

b.

Tracheal obstruction related to aspiration of a hot dog

c.

Anxiety-induced hyperventilation in an adolescent

d.

Diarrhea for 36 hours in an older, frail woman

ANS: B

Arterial blood gas values indicate that the client is in acidosis and has 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 the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

20. Which client does the nurse assess for potential metabolic acidosis?

a.

Client admitted after collapsing during a marathon run

b.

Young adult following a carbohydrate-free diet

c.

Older adult with asthma who is on long-term steroid therapy

d.

Older client on antacids for gastroesophageal reflux disease

ANS: B

One cause of acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. Dehydration is not directly associated with acid-base disorders. In the client with asthma, acid-base status will be determined by a combination of depth of respirations and oxygen saturation. Excessive intake of sodium bicarbonate may increase the risk of metabolic alkalosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

21. The nurse interprets which arterial blood gas values as partially compensated metabolic acidosis?

a.

pH 7.28, HCO3 19 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg

b.

pH 7.45, HCO3 22 mEq/L, PCO2 40 mm Hg, PO2 98 mm Hg

c.

pH 7.32, HCO3 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg

d.

pH 7.48, HCO3 28 mEq/L, PCO2 45 mm Hg, PO2 92 mm Hg

ANS: C

The pH is lower than normal, indicating mild acidosis. The acidosis is metabolic in origin, as indicated by the normal arterial oxygen partial pressure and the low bicarbonate level. The decreased carbon dioxide level indicates an increased respiratory rate, causing the carbon dioxide to be blown off and bringing the pH closer to normal (but not completely normal). Thus, the metabolic acidosis is only partially compensated for by the respiratory effort.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

22. A client has just experienced a 90-second tonic-clonic seizure and has these arterial blood gas values: pH 6.88, HCO3 22 mEq/L, PCO2 60 mm Hg, PO2 50 mm Hg. Which intervention by the nurse is most appropriate?

a.

Apply oxygen by mask or nasal cannula.

b.

Apply a paper bag over the clients nose and mouth.

c.

Administer 50 mL of sodium bicarbonate intravenously.

d.

Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: A

The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return to acid-base balance is to administer oxygen. Sodium bicarbonate should not be administered because the clients arterial bicarbonate level is normal. Applying a paper bag over the clients nose and mouth would worsen the acidosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

23. A client who was malnourished is being discharged. The nurse evaluates that teaching to decrease risk for the development of metabolic acidosis has been effective when the client states, I will:

a.

Increase my milk intake to at least three glasses daily.

b.

Be sure to eat three well-balanced meals and a snack daily.

c.

Avoid taking pain medication and antihistamines together.

d.

Not add salt to food when cooking or during meals.

ANS: B

Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

24. The nurse assesses the client with which condition most carefully for the risk of developing acute respiratory acidosis?

a.

Allergic rhinitis and sinusitis on sulfa antibiotics

b.

Type 1 diabetes and urinary tract infection

c.

Emphysema and undergoing nasogastric (NG) tube suctioning

d.

On patient-controlled analgesia after abdominal surgery

ANS: D

Respiratory acidosis often occurs as the result of underventilation. The client who is taking narcotics, especially IV narcotics, is at risk for respiratory depression. The client may also be breathing more shallowly than usual to prevent pain. This gives the client two risk factors for developing hypoventilation and subsequent respiratory acidosis. None of the other clients are at risk for ineffective ventilation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications Related to Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

25. The nurse correlates which condition with the following arterial blood gas values: pH 7.48, HCO3 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?

a.

Diarrhea and vomiting for 36 hours

b.

Anxiety-induced hyperventilation

c.

Chronic obstructive pulmonary disease

d.

Diabetic ketoacidosis and emphysema

ANS: B

The elevated pH indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the person with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

26. A postoperative client received six units of packed red blood cells (PRBCs) for intraoperative blood loss. The nurse monitors the client for which acid-base imbalance?

a.

Metabolic alkalosis

b.

Metabolic acidosis

c.

Respiratory alkalosis

d.

Respiratory acidosis

ANS: A

Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate (bicarbonate can be formed from citrate). Rapid administration of blood products can cause metabolic alkalosis by infusing large amounts of citrate intravenously. Although this problem is more likely to occur with administration of whole blood or blood plasma, multiple transfusions with packed red cells can also result in excessive amounts of citrate being received by the client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

27. A client has severe metabolic alkalosis. Which nursing diagnosis does the nurse choose as the clients priority problem?

a.

Fluid volume excess related to reduced kidney function

b.

Fluid volume deficit related to increased insensitive fluid loss through lungs

c.

Risk for impaired skin integrity related to accompanying peripheral edema

d.

Risk for injury related to increased neuronal sensitivity from hypocalcemia

ANS: D

Metabolic alkalosis is manifested by a high pH, which causes serum calcium to bind and reduces the concentration of free calcium. This relative hypocalcemia increases the risk for increased neuromuscular activity, including tetany and seizures.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Diagnosis)

28. A client has respiratory acidosis. The nurse evaluates that treatment is being effective with which arterial blood gas values?

a.

pH 7.28, HCO3 12 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg

b.

pH 7.32, HCO3 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg

c.

pH 7.35, HCO3 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg

d.

pH 7.48, HCO3 12 mEq/L, PCO2 35 mm Hg, PO2 85 mm Hg

ANS: C

A pH of 7.35 is normal, indicating acid-base balance (fully compensated). A respiratory problem with carbon dioxide retention and inadequate gas exchange is apparent from the high PCO2 and the low PO2. The bicarbonate level is greatly elevated, indicating renal synthesis and reabsorption of HCO3, a powerful acid-base compensatory mechanism. Thus, the amount of bicarbonate (base) in the blood adequately compensates for the increased carbon dioxide level, so that the pH is normal, although no other arterial blood gas value is normal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Evaluation)

29. The nurse monitors the client with which condition most carefully for metabolic alkalosis?

a.

A critical illness receiving total parenteral nutrition

b.

Type 1 diabetes on once-daily insulin therapy

c.

Metastatic breast cancer on continuous IV morphine

d.

Asthma using an adrenergic agonist inhaler

ANS: A

The IV fluid mixture for total parenteral nutrition (TPN) has an overall basic pH. One common substance in TPN is lactate, which is rapidly converted in the body to bicarbonate. In addition, the TPN mixture is often administered as a continuous slow infusion. A client with diabetes would be at higher risk of metabolic acidosis. The client on IV morphine is more at risk for respiratory acidosis, as is the client with asthma.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

30. A client is in the emergency department after an overdose of an unknown substance. Which assessment findings does the nurse correlate with possible salicylate poisoning?

a.

Increased deep tendon reflexes

b.

Increased rate and depth of respiration

c.

Decreased capillary refill

d.

Decreased intestinal motility and paralytic ileus

ANS: B

Salicylates are acidic, and salicylate poisoning increases the rate and depth of ventilation in two ways. First, salicylates directly stimulate the respiratory centers. Second, by causing a metabolic acidosis and reducing the pH of the blood, the respiratory centers are stimulated to compensate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

31. A client has a prolonged fever. For which acid-base imbalance does the nurse assess the client further?

a.

Metabolic acidosis from excess bicarbonate production

b.

Metabolic alkalosis from dehydration and hyperkalemia

c.

Metabolic acidosis from increased production of hydrogen ions

d.

Respiratory alkalosis from impaired gas exchange

ANS: C

Increased body temperature is associated with hypermetabolism and increases the rate at which hydrogen ions are produced. Increased bicarbonate production would lead to metabolic alkalosis. Hyperkalemia leads to metabolic acidosis. Having a fever would not directly lead to gas exchange problems.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

32. The nurse is providing discharge teaching. Which statement by the client indicates the need for further teaching regarding increased risk for metabolic alkalosis?

a.

I dont drink milk because it gives me gas and diarrhea.

b.

I have been taking digoxin every day for the last 15 years.

c.

I take sodium bicarbonate after every meal to prevent heartburn.

d.

In hot weather, I sweat so much that I drink six glasses of water each day.

ANS: C

Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause a metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

33. A client with chronic respiratory acidosis is receiving oxygen by nasal cannula at 6 L/min. The clients respiratory rate is 8 breaths/min. Which action by the nurse is the priority?

a.

Notify the Rapid Response Team and prepare for intubation.

b.

Change the nasal cannula to a mask and reassess in 10 minutes.

c.

Place the client in Fowlers position if he or she is able to tolerate it.

d.

Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.

ANS: A

The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the clients respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10. Changing the cannula to a mask does nothing to improve the clients hypoxic drive, nor would it address the clients most pressing need. Positioning will not help the client breathe at a normal rate nor maintain client safety.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

34. A client is being discharged from the emergency department with several broken ribs. For which acid-base imbalance does the nurse provide discharge teaching?

a.

Respiratory alkalosis from anxiety and hyperventilation

b.

Respiratory acidosis from inadequate ventilation

c.

Metabolic acidosis from calcium loss from broken bones

d.

Metabolic alkalosis from taking base-containing analgesics

ANS: B

Pain from broken ribs often causes the client to breathe more shallowly to avoid moving his or her ribs and increasing pain. If respiration is shallow enough, ventilation is inadequate, leading to poor gas exchange and respiratory acidosis. Hyperventilation would more likely cause respiratory alkalosis. The calcium loss from broken ribs probably would not affect acid-base balance. Taking analgesics as prescribed for pain probably also would not affect acid-base balance.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)

35. The nurse prepares to administer bicarbonate intravenously to the client with which clinical manifestations?

a.

pH 7.28, HCO3 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg secondary to an acute asthma attack

b.

pH 7.28, HCO3 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea

c.

Client with chronic emphysema and bronchitis who has the following arterial blood gases: pH 7.30, HCO3 30 mEq/L, PCO2 60 mm Hg, PO2 72 mm Hg secondary to chronic bronchitis and emphysema

d.

pH 7.31, HCO3 20 mEq/L, PCO2 34 mm Hg, PO2 96 mm Hg secondary to a urinary tract infection and type 2 diabetes

ANS: B

The only client who has lower than normal bicarbonate levels is the client with diarrhea. This deficit is most likely the result of an actual bicarbonate loss, and bicarbonate should be replaced to help return this clients acid-base balance to normal. Giving bicarbonate to any of the other clients listed would be adding too much base and would risk the development of alkalosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

36. A client has metabolic alkalosis. Which laboratory results is the nurse most likely to assess as consistent with this condition?

a.

Na+ 134 mg/dL

b.

Mg2+ 1.5 mg/dL

c.

K+ 3.1 mEq/L

d.

Ca2+ 11.5 mg/dL

ANS: C

Both potassium and hydrogen ions carry or express an overall positive charge (cations). Body fluids maintain electroneutrality by keeping the number of positive ions matched with an equal number of negative ions (anions). A compensation of alkalosis is the movement of hydrogen ions into cells inside the blood and other extracellular fluids. To prevent the blood from expressing too many positive charges, another positive ion must leave the blood and enter the cells. Potassium is the positive ion that usually is exchanged for a hydrogen ion. Thus, a relative hypokalemia usually accompanies alkalosis as extracellular potassium ions move into cells in exchange for intracellular hydrogen ions entering the extracellular fluid.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

37. A client is admitted with mixed respiratory and metabolic acidosis secondary to bronchitis and diabetic ketoacidosis. The nurse evaluates that teaching about the clients confusion was effective when a family member makes which statement?

a.

It is too early to tell if the ketoacidosis will cause permanent changes.

b.

Her memory will improve, but loss of some brain cells has occurred.

c.

The confusion should clear when oxygen and electrolyte levels are normal.

d.

The confusion should clear when blood glucose levels and other laboratory tests are normal.

ANS: C

The pH abnormality alone is not responsible for the confusion. Most of the confusion is caused by hypoxia in combination with electrolyte imbalances that accompany severe combined acidosis. None of the other options address the clients hypoxia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

38. A client is being discharged and continues to be at risk for developing metabolic alkalosis. Which statement by the client indicates to the nurse that teaching has been effective?

a.

I will avoid excess use of antacids.

b.

Ill drink at least three glasses of milk daily.

c.

Ill avoid medications containing aspirin.

d.

I will not add salt to my food during meals.

ANS: A

Many antacids contain bicarbonate or calcium carbonate, both of which (when taken in excess) can increase the bicarbonate content of the blood and other extracellular fluids, increasing the risk for alkalosis even further. None of the other options address a risk factor for developing metabolic alkalosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Assessment)

39. In clients with any type of acid-base imbalance, the nurse places the priority on monitoring which electrolyte?

a.

Sodium

b.

Calcium

c.

Potassium

d.

Magnesium

ANS: C

Any type of acid-base imbalance usually alters the blood potassium level. Both potassium and hydrogen ions carry or express an overall positive charge (cations). Body fluids maintain electroneutrality by keeping the number of positive ions matched with an equal number of negative ions (anions). In acidosis, hydrogen ions enter cells in exchange for potassium ions. Thus, a relative hyperkalemia accompanies acidosis. In alkalosis, hydrogen ions leave the cells and enter the blood in exchange for potassium ions. Thus, a relative hypokalemia usually accompanies alkalosis as extracellular potassium ions move into cells in exchange for intracellular hydrogen ions entering the extracellular fluid. The normal potassium level of the blood has a narrow range (3.5 to 5.0 mEq/L). When blood potassium levels are too high, lethal cardiac dysrhythmias may occur. When blood potassium levels are too low, skeletal muscle weakness and respiratory failure may occur.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

40. A client has acidosis. Which laboratory finding is of greatest concern to the nurse?

a.

Sodium 154 mEq/L

b.

Potassium 5.9 mEq/L

c.

Calcium 8.9 mg/dL

d.

Magnesium 2.1 mg/dL

ANS: B

In the client with acidosis, intracellular buffering leads to entry of hydrogen ions (H+) into cells, and in return potassium leaves the cell. This leads to elevated serum potassium levels. Many severe problems with acidosis are due to the accompanying hyperkalemia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

41. A client has the following arterial blood gases: pH 7.30, HCO3 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg. Which intervention by the nurse is most appropriate?

a.

Prepare to give intravenous sodium bicarbonate.

b.

Document the findings and continue to assess.

c.

Assist the physician in determining the cause.

d.

Administer oxygen at 2 L per nasal cannula.

ANS: C

The client has a partially compensated metabolic acidosis. Interventions are aimed at reducing or eliminating the cause. The nurse needs to assist in determining the cause so that proper interventions can be initiated. Sodium bicarbonate is rarely used for acidosis unless the pH is life threatening, or for specific causes of acidosis wherein bicarbonate deficit is known to be the problem. Simply documenting the findings will not help the client. Because the clients PO2 is 98 mm Hg, oxygen therapy is not indicated on the basis of these arterial blood gases.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

42. A client has the following arterial blood gases (ABGs): pH 7.30, HCO3 22 mEq/L, PCO2 55 mm Hg, PO2 86 mm Hg. Which intervention by the nurse takes priority?

a.

Assessing the airway

b.

Administering bronchodilators

c.

Administering mucolytics

d.

Providing oxygen

ANS: A

All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

43. A client has been NPO after a colectomy with nasogastric (NG) suction in place. On assessment, the nurse finds the client reporting cramps in the calves. Which action by the nurse is most appropriate?

a.

Document findings and notify the physician.

b.

Stop suction and request that the laboratory draw arterial blood gases.

c.

Prepare to administer lorazepam (Ativan).

d.

Raise the siderails and notify the physician.

ANS: D

The client has a metabolic alkalosis probably caused by prolonged suctioning. The client also is experiencing tetany, caused by the accompanying hypocalcemia, and is at risk for seizures. The priority is to maintain the clients safety; this includes raising the siderails and then notifying the physician. Documentation is important but not as important as providing safety. The nurse would not stop the suction without an order. The client may need lorazepam if he or she has seizures, but this is not the first action the nurse would perform.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1. In the client with alkalosis, the nurse assesses for which clinical manifestations? (Select all that apply.)

a.

Positive Chvosteks sign

b.

Positive Trousseaus sign

c.

Hyporeflexia

d.

Bradycardia

e.

Elevated blood pressure

f.

Elevated urinary output

ANS: A, B, D

The client with alkalosis demonstrates signs of hypocalcemia and decreased heart rate. Many symptoms are the result of low calcium levels (hypocalcemia) and low potassium levels (hypokalemia), which usually occur with alkalosis. These problems change the function of the nervous, neuromuscular, cardiac, and respiratory systems.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 208

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

Leave a Reply