Module 1 Acid-Base Balance(FREE) My Nursing Test Banks

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 1 Acid-Base Balance

The Concept of Acid-Base Balance

1) A client is brought to the Emergency Department after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client?

A) Metabolic acidosis

B) Respiratory alkalosis

C) Metabolic alkalosis

D) Respiratory acidosis

Answer: A

Explanation: A) A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Starvation would not result in respiratory acidosis or alkalosis or in metabolic alkalosis.

B) A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Starvation would not result in respiratory acidosis or alkalosis or in metabolic alkalosis.

C) A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Starvation would not result in respiratory acidosis or alkalosis or in metabolic alkalosis.

D) A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Starvation would not result in respiratory acidosis or alkalosis or in metabolic alkalosis.

Page Ref: 14

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Summarize the physiology of acid-base balance.

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2) Which of the following risk factors exhibited by the client presenting in the Emergency Department would place the client at risk for metabolic acidosis?

Select all that apply.

A) Abdominal fistulas

B) Chronic obstructive pulmonary disease

C) Pneumonia

D) Acute renal failure

E) Hypovolemic shock

Answer: A, D, E

Explanation: A) Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; and acute renal failure. Chronic obstructive pulmonary disease and pneumonia place the client at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.

B) Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; and acute renal failure. Chronic obstructive pulmonary disease and pneumonia place the client at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.

C) Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; and acute renal failure. Chronic obstructive pulmonary disease and pneumonia place the client at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.

D) Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; and acute renal failure. Chronic obstructive pulmonary disease and pneumonia place the client at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.

E) Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas; which can cause excess bicarbonate loss; and acute renal failure. Chronic obstructive pulmonary disease and pneumonia place the client at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.

Page Ref: 14

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Examine the relationship between acid-base balance and other concepts/systems.

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3) A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets this as which of the following?

A) Metabolic acidosis

B) Respiratory alkalosis

C) Respiratory acidosis

D) Metabolic alkalosis

Answer: C

Explanation: A) If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. In addition, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased PaCO2, and normal HCO3. Uncompensated metabolic acidosis has a decreased pH, normal PaCO2, and normal HCO3. Uncompensated metabolic alkalosis has an increased pH, normal PaCO2, and increased HCO3.

B) If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. In addition, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased PaCO2, and normal HCO3. Uncompensated metabolic acidosis has a decreased pH, normal PaCO2, and normal HCO3. Uncompensated metabolic alkalosis has an increased pH, normal PaCO2, and increased HCO3.

C) If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. In addition, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased PaCO2, and normal HCO3. Uncompensated metabolic acidosis has a decreased pH, normal PaCO2, and normal HCO3. Uncompensated metabolic alkalosis has an increased pH, normal PaCO2, and increased HCO3.

D) If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. In addition, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased PaCO2, and normal HCO3. Uncompensated metabolic acidosis has a decreased pH, normal PaCO2, and normal HCO3. Uncompensated metabolic alkalosis has an increased pH, normal PaCO2, and increased HCO3.

Page Ref: 9

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 3. Identify commonly occurring alterations in acid-base balance and their related therapies.

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4) The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated?

A) pH 7.32

B) PaCO2 18 mmHg

C) HCO3 8 mEq/L

D) PaCO2 48 mmHg

Answer: D

Explanation: A) A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis. A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis. A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis. In metabolic alkalosis, there is an excess of bicarbonate. To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated.

B) A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis. A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis. A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis. In metabolic alkalosis, there is an excess of bicarbonate. To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated.

C) A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis. A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis. A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis. In metabolic alkalosis, there is an excess of bicarbonate. To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated.

D) A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis. A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis. A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis. In metabolic alkalosis, there is an excess of bicarbonate. To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated.

Page Ref: 9

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Evaluation

Learning Outcome: 4. Differentiate common assessment procedures used to examine acid-base balance across the life span.

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5) A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the clients acid-base balance?

A) Arterial blood gases (ABGs)

B) Pulse oximetry

C) Sputum studies

D) Bronchoscopy

Answer: A

Explanation: A) ABGs are done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both. A bronchoscopy provides visualization of internal respiratory structures. Sputum studies can provide specific information about bacterial organisms. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.

B) ABGs are done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both. A bronchoscopy provides visualization of internal respiratory structures. Sputum studies can provide specific information about bacterial organisms. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.

C) ABGs are done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both. A bronchoscopy provides visualization of internal respiratory structures. Sputum studies can provide specific information about bacterial organisms. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.

D) ABGs are done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both. A bronchoscopy provides visualization of internal respiratory structures. Sputum studies can provide specific information about bacterial organisms. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.

Page Ref: 4

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individuals acid-base balance status.

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6) The nurse is instructing a client with a history of acidosis on the use of sodium bicarbonate. Which client statement indicates that additional teaching is needed?

A) I should contact the doctor if I have any gastric discomfort with chest pain.

B) I need to purchase antacids without salt.

C) I should use the antacid for at least 2 months.

D) I should call the doctor if I get short of breath or start to sweat with this medication.

Answer: C

Explanation: A) The client should be instructed to immediately contact the primary healthcare provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis occurs. The client should be instructed to use non-sodium antacids to prevent the absorption of excess sodium or bicarbonate into systemic circulation and to not use any bicarbonate antacid for longer than 2 weeks.

B) The client should be instructed to immediately contact the primary healthcare provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis occurs. The client should be instructed to use non-sodium antacids to prevent the absorption of excess sodium or bicarbonate into systemic circulation and to not use any bicarbonate antacid for longer than 2 weeks.

C) The client should be instructed to immediately contact the primary healthcare provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis occurs. The client should be instructed to use non-sodium antacids to prevent the absorption of excess sodium or bicarbonate into systemic circulation and to not use any bicarbonate antacid for longer than 2 weeks.

D) The client should be instructed to immediately contact the primary healthcare provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis occurs. The client should be instructed to use non-sodium antacids to prevent the absorption of excess sodium or bicarbonate into systemic circulation and to not use any bicarbonate antacid for longer than 2 weeks.

Page Ref: 12

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation/Teaching and Learning

Learning Outcome: 6. Explain management of acid-base balance and prevention of acid-base imbalance.

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7) A client who was diagnosed with diabetes mellitus 1 year ago is hospitalized in diabetic ketoacidosis after a religious fast. The client tells the nurse, I have fasted during this season every year since I became an adult. I am not going to stop now. The nurse is not knowledgeable about this particular religion. Which nursing action would be appropriate?

Select all that apply.

A) Request a consult from a diabetes educator.

B) Tell the client that things are different now because of the diabetes.

C) Ask family members of the same religion to discuss fasting with the client.

D) Assess the meaning and context of fasting in the clients religion.

E) Encourage the client to seek medical care if signs of ketoacidosis occur in the future.

Answer: A, D, E

Explanation: A) The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Assessing the meaning and context of fasting in the clients religion would be educative for the nurse and an appropriate action. Stressing the importance of promptly seeking care when signs of ketoacidosis occur helps to promote the clients health and is appropriate. Telling the client that life is different now does not support religious beliefs. Asking the family to talk to the client might help, but the diabetes educator would be able to provide more direct and helpful information for the client.

B) The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Assessing the meaning and context of fasting in the clients religion would be educative for the nurse and an appropriate action. Stressing the importance of promptly seeking care when signs of ketoacidosis occur helps to promote the clients health and is appropriate. Telling the client that life is different now does not support religious beliefs. Asking the family to talk to the client might help, but the diabetes educator would be able to provide more direct and helpful information for the client.

C) The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Assessing the meaning and context of fasting in the clients religion would be educative for the nurse and an appropriate action. Stressing the importance of promptly seeking care when signs of ketoacidosis occur helps to promote the clients health and is appropriate. Telling the client that life is different now does not support religious beliefs. Asking the family to talk to the client might help, but the diabetes educator would be able to provide more direct and helpful information for the client.

D) The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Assessing the meaning and context of fasting in the clients religion would be educative for the nurse and an appropriate action. Stressing the importance of promptly seeking care when signs of ketoacidosis occur helps to promote the clients health and is appropriate. Telling the client that life is different now does not support religious beliefs. Asking the family to talk to the client might help, but the diabetes educator would be able to provide more direct and helpful information for the client.

E) The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner. Assessing the meaning and context of fasting in the clients religion would be educative for the nurse and an appropriate action. Stressing the importance of promptly seeking care when signs of ketoacidosis occur helps to promote the clients health and is appropriate. Telling the client that life is different now does not support religious beliefs. Asking the family to talk to

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the client might help, but the diabetes educator would be able to provide more direct and helpful information for the client.

Copyright 2015 Pearson Education, Inc.

Page Ref: 11

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and caring interventions across the life span for individuals with common alterations in acid-base balance.

8) The client is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the client to be lethargic, confused, and breathing rapidly. What is the nurses priority response to the situation?

A) Stop the infusion and notify the physician because the client is in alkalosis.

B) Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis.

C) Continue the infusion, because the client is still in acidosis, and notify the physician.

D) Increase the rate of the infusion and continue to assess the client for symptoms of acidosis.

Answer: C

Explanation: A) The client receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The clients symptoms do not indicate alkalosis so infusion should not be stopped. The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid, and the physician should be notified. The infusion should not be increased or decreased without a practitioner order.

B) The client receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The clients symptoms do not indicate alkalosis so infusion should not be stopped. The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid, and the physician should be notified. The infusion should not be increased or decreased without a practitioner order.

C) The client receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The clients symptoms do not indicate alkalosis so infusion should not be stopped. The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid, and the physician should be notified. The infusion should not be increased or decreased without a practitioner order.

D) The client receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The clients symptoms do not indicate alkalosis so infusion should not be stopped. The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid, and the physician should be notified. The infusion should not be increased or decreased without a practitioner order.

Page Ref: 12

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 8. Compare and contrast common independent and collaborative interventions for

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clients with alterations in acid-base balance.

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9) The nurse is preparing to analyze a clients arterial blood gas results. List the steps in the order that the nurse should follow when analyzing this laboratory test.

1. Look at the PaCO2.

2. Look at the pH.

3. Evaluate the relationship between pH and PaCO2.

4. Look for compensation.

5. Evaluate the pH, HCO3, and base excess for a possible metabolic problem.

6. Look at the bicarbonate.

7. Evaluate oxygenation.

Answer: 2, 1, 3, 6, 5, 4, 7

Explanation:

1. The pH is the first step and is analyzed to determine if acidosis or alkalosis is present. A pH of less than 7.35 is acidosis. A pH greater than 7.45 is alkalosis.

2. If the PaCO2 is less than 35, then more carbon dioxide is being exhaled. If the PaCO2 is greater than 45, then more carbon dioxide is being retained.

3. This relationship could indicate a respiratory problem. If the pH is acidotic and the carbon dioxide level is greater than 45, then the client could be experiencing respiratory acidosis. If the pH is alkalotic and the carbon dioxide level is below 35, then the client could be experiencing respiratory alkalosis.

4. If the bicarbonate level is less than 24, then the levels are lower than normal. If the bicarbonate level is greater than 28, then the bicarbonate levels are higher than normal.

5. If the pH is < 7.35, the HCO3 is < 24 mEq/L, and the BE is < 2 mEq/L, then low bicarbonate levels and high H + concentrations are causing metabolic acidosis. If the pH is > 7.45, the HCO3 is > 28 mEq/L, and the BE is > +2 mEq/L, then high bicarbonate levels are causing metabolic alkalosis.

6. Two things can occur in renal compensation. In respiratory acidosis, the kidneys retain HCO3 to buffer the excess acid, so the HCO3 is > 28 mEq/L. In respiratory alkalosis, the kidneys excrete HCO3 to minimize the alkalosis, so the HCO3 is < 24 mEq/L. Two things can also occur in respiratory compensation. In metabolic acidosis the rate and depth of respirations increase, increasing carbon dioxide elimination, so the PaCO2 is < 35 mmHg. In metabolic alkalosis respirations slow and carbon dioxide is retained, so the PaCO2 is > 45 mmHg.

7. If the PaO2 is less than 75 mmHg, then the client is experiencing hypoxemia and possible hypoventilation. If the PaO2 is greater than 100 mmHg, then the client is hyperventilating.

Page Ref: 11

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing Process: Assessment

Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individuals acid-base balance status.

Copyright 2015 Pearson Education, Inc.

10) The nurse is identifying a diagram to use to explain a clients acid-base balance. Which imbalance does the following diagram suggest is occurring with the client?

A) Metabolic acidosis

B) Metabolic alkalosis

C) Respiratory acidosis

D) Respiratory alkalosis

Answer: A

Explanation: A) In metabolic acidosis, the amount of bicarbonate decreases in relation to the amount of acid in the body. In metabolic alkalosis, there is an excess of bicarbonate in relation to the amount of hydrogen ions. Respiratory acidosis occurs when carbon dioxide is retained, increasing the amount of carbonic acid in the body. Respiratory alkalosis can occur when too much carbon dioxide is lost and carbonic acid levels fall.

B) In metabolic acidosis, the amount of bicarbonate decreases in relation to the amount of acid in the body. In metabolic alkalosis, there is an excess of bicarbonate in relation to the amount of hydrogen ions. Respiratory acidosis occurs when carbon dioxide is retained, increasing the amount of carbonic acid in the body. Respiratory alkalosis can occur when too much carbon dioxide is lost and carbonic acid levels fall.

C) In metabolic acidosis, the amount of bicarbonate decreases in relation to the amount of acid in the body. In metabolic alkalosis, there is an excess of bicarbonate in relation to the amount of hydrogen ions. Respiratory acidosis occurs when carbon dioxide is retained, increasing the amount of carbonic acid in the body. Respiratory alkalosis can occur when too much carbon dioxide is lost and carbonic acid levels fall.

D) In metabolic acidosis, the amount of bicarbonate decreases in relation to the amount of acid in the body. In metabolic alkalosis, there is an excess of bicarbonate in relation to the amount of hydrogen ions. Respiratory acidosis occurs when carbon dioxide is retained, increasing the amount of carbonic

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acid in the body. Respiratory alkalosis can occur when too much carbon dioxide is lost and carbonic acid levels fall.

Page Ref: 7

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 1. Summarize the physiology of acid-base balance.

11) The nurse is planning care for an older client with respiratory acidosis. Which intervention should the nurse include in this clients plan of care?

A) Administer prescribed intravenous fluids carefully.

B) Administer intravenous sodium bicarbonate.

C) Maintain adequate hydration.

D) Reduce environmental stimuli.

Answer: C

Explanation: A) In respiratory acidosis, there are a drop in the blood pH, reduced level of oxygen, and retaining of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation. Careful administration of intravenous fluids is important in the older client with metabolic alkalosis because older clients are at risk because of their fragile fluid and electrolyte status. Sodium bicarbonate is indicated in the treatment of metabolic acidosis. Reducing environmental stimuli would be appropriate for the client with respiratory alkalosis.

B) In respiratory acidosis, there are a drop in the blood pH, reduced level of oxygen, and retaining of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation. Careful administration of intravenous fluids is important in the older client with metabolic alkalosis because older clients are at risk because of their fragile fluid and electrolyte status. Sodium bicarbonate is indicated in the treatment of metabolic acidosis. Reducing environmental stimuli would be appropriate for the client with respiratory alkalosis.

C) In respiratory acidosis, there are a drop in the blood pH, reduced level of oxygen, and retaining of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation. Careful administration of intravenous fluids is important in the older client with metabolic alkalosis because older clients are at risk because of their fragile fluid and electrolyte status. Sodium bicarbonate is indicated in the treatment of metabolic acidosis. Reducing environmental stimuli would be appropriate for the client with respiratory alkalosis.

D) In respiratory acidosis, there are a drop in the blood pH, reduced level of oxygen, and retaining of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation. Careful administration of intravenous fluids is important in the older client with metabolic alkalosis because older clients are at risk because of their fragile fluid and electrolyte status. Sodium bicarbonate is indicated in the treatment of metabolic acidosis. Reducing environmental stimuli would be appropriate for the client with respiratory alkalosis.

Page Ref: 23

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Planning

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Learning Outcome: 6. Explain management of acid-base balance and prevention of acid-base imbalance.

12) The results of a clients arterial blood gas sample reveal an oxygen level of 72 mmHg. For which associated health problem should the nurse assess this client?

A) Communication

B) Perfusion

C) Fluid and electrolyte imbalance

D) Cognition

Answer: D

Explanation: A) An oxygen level of less than 75 mmHg can be due to hypoventilation. This drop in oxygen will change the clients level of responsiveness. Although acid-base imbalances can alter communication, there is no direct link between a low oxygen level and changes in communication. Perfusion is affected by a reduction in circulating fluids. With a fluid and electrolyte imbalance, there is another disorder affecting acid-base balance. This might not be affected by oxygen level.

B) An oxygen level of less than 75 mmHg can be due to hypoventilation. This drop in oxygen will change the clients level of responsiveness. Although acid-base imbalances can alter communication, there is no direct link between a low oxygen level and changes in communication. Perfusion is affected by a reduction in circulating fluids. With a fluid and electrolyte imbalance, there is another disorder affecting acid-base balance. This might not be affected by oxygen level.

C) An oxygen level of less than 75 mmHg can be due to hypoventilation. This drop in oxygen will change the clients level of responsiveness. Although acid-base imbalances can alter communication, there is no direct link between a low oxygen level and changes in communication. Perfusion is affected by a reduction in circulating fluids. With a fluid and electrolyte imbalance, there is another disorder affecting acid-base balance. This might not be affected by oxygen level.

D) An oxygen level of less than 75 mmHg can be due to hypoventilation. This drop in oxygen will change the clients level of responsiveness. Although acid-base imbalances can alter communication, there is no direct link between a low oxygen level and changes in communication. Perfusion is affected by a reduction in circulating fluids. With a fluid and electrolyte imbalance, there is another disorder affecting acid-base balance. This might not be affected by oxygen level.

Page Ref: 5

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 2. Examine the relationship between acid-base balance and other concepts/systems.

Copyright 2015 Pearson Education, Inc.

13) The nurse is caring for a comatose client with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this client?

A) Measuring vital signs

B) Measuring intake and output

C) The clients recent eating behaviors

D) Identifying current oxygen saturation level

Answer: C

Explanation: A) For clients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting. Measuring vital signs is an independent nursing action. Measuring intake and output is an independent nursing action. Identifying current oxygen saturation level is an independent nursing action.

B) For clients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting. Measuring vital signs is an independent nursing action. Measuring intake and output is an independent nursing action. Identifying current oxygen saturation level is an independent nursing action.

C) For clients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting. Measuring vital signs is an independent nursing action. Measuring intake and output is an independent nursing action. Identifying current oxygen saturation level is an independent nursing action.

D) For clients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting. Measuring vital signs is an independent nursing action. Measuring intake and output is an independent nursing action. Identifying current oxygen saturation level is an independent nursing action.

Page Ref: 22

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 8. Compare and contrast common independent and collaborative interventions for clients with alterations in acid-base balance.

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Exemplar 1.1 Metabolic Acidosis

1) The nurse is analyzing the clients arterial blood gas report, which reveals a pH of 6.58. The client has just suffered a cardiac arrest. Which of the following consequences does the nurse consider for this client?

A) Decreased cardiac output

B) Increase magnesium levels

C) Decreased free calcium in the ECT

D) Increased myocardial contractility

Answer: A

Explanation: A) The nurse knows that severe acidosis (pH of 7.0 or less) depresses myocardial contractility, which leads to decreased cardiac output. Acid-base imbalances also affect electrolyte balance. In acidosis, potassium is retained as the kidney excretes excess hydrogen ion. Excess hydrogen ions also enter the cells, displacing potassium from the intracellular space to maintain the balance of cations and anions within the cells. The effect of both processes is to increase serum potassium levels. Also in acidosis, calcium is released from its bonds with plasma proteins, increasing the amount of ionized (free) calcium in the blood. Magnesium levels may fall in acidosis.

B) The nurse knows that severe acidosis (pH of 7.0 or less) depresses myocardial contractility, which leads to decreased cardiac output. Acid-base imbalances also affect electrolyte balance. In acidosis, potassium is retained as the kidney excretes excess hydrogen ion. Excess hydrogen ions also enter the cells, displacing potassium from the intracellular space to maintain the balance of cations and anions within the cells. The effect of both processes is to increase serum potassium levels. Also in acidosis, calcium is released from its bonds with plasma proteins, increasing the amount of ionized (free) calcium in the blood. Magnesium levels may fall in acidosis.

C) The nurse knows that severe acidosis (pH of 7.0 or less) depresses myocardial contractility, which leads to decreased cardiac output. Acid-base imbalances also affect electrolyte balance. In acidosis, potassium is retained as the kidney excretes excess hydrogen ion. Excess hydrogen ions also enter the cells, displacing potassium from the intracellular space to maintain the balance of cations and anions within the cells. The effect of both processes is to increase serum potassium levels. Also in acidosis, calcium is released from its bonds with plasma proteins, increasing the amount of ionized (free) calcium in the blood. Magnesium levels may fall in acidosis.

D) The nurse knows that severe acidosis (pH of 7.0 or less) depresses myocardial contractility, which leads to decreased cardiac output. Acid-base imbalances also affect electrolyte balance. In acidosis, potassium is retained as the kidney excretes excess hydrogen ion. Excess hydrogen ions also enter the cells, displacing potassium from the intracellular space to maintain the balance of cations and anions within the cells. The effect of both processes is to increase serum potassium levels. Also in acidosis, calcium is released from its bonds with plasma proteins, increasing the amount of ionized (free) calcium in the blood. Magnesium levels may fall in acidosis.

Page Ref: 16

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of metabolic acidosis.

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2) The mother of a 1-month-old infant calls the nurse who works in the health clinic. The mother is concerned because the infant has had vomiting and diarrhea for 2 days. The nurse knows that this infant is at risk for metabolic acidosis. Which of the following is the priority nursing action?

A) Instruct the mother to provide the infant with 50 mL of glucose water.

B) Instruct the mother to measure the infants urine output for 24 hours.

C) Instruct the mother to give the infant at least 2 ounces of juice every 2 hours.

D) Instruct the mother to bring the infant to the clinic for evaluation.

Answer: D

Explanation: A) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and neither juice nor glucose water is the best choice of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.

B) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and neither juice nor glucose water is the best choice of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.

C) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and neither juice nor glucose water is the best choice of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.

D) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and neither juice nor glucose water is the best choice of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.

Page Ref: 10

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

3) The nurse is assessing an African-American client whose cultural background is different from the cultural background of the nurse. The client has symptoms of metabolic acidosis. Which of the following situations would illustrate stereotypical behavior on the nurses part?

Select all that apply.

A) Understanding that all culture members will have the same beliefs

B) Bringing previous negative information and experiences into this situation

C) Making an assumption that all members of each culture are alike

D) Taking general knowledge from literature and applying it to the situation

E) Discussing the clients health status with family members

Answer: A, B, C, D

Explanation: A) Options 1, 2, 3, and 4 describe stereotypical behavior, which is assuming that all members of a culture or ethnic group are alike. Option 2 describes prejudice. Prejudice is a negative belief or preference that is generalized about a group, which leads to prejudgment. Prejudice occurs when the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Discussing the clients health status with family members is not stereotypical behavior and would be considered a violation of the privacy laws if the client did not provide permission for disclosure of personal health information.

B) Options 1, 2, 3, and 4 describe stereotypical behavior, which is assuming that all members of a culture or ethnic group are alike. Option 2 describes prejudice. Prejudice is a negative belief or preference that is generalized about a group, which leads to prejudgment. Prejudice occurs when the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Discussing the clients health status with family members is not stereotypical behavior and would be considered a violation of the privacy laws if the client did not provide permission for disclosure of personal health information.

C) Options 1, 2, 3, and 4 describe stereotypical behavior, which is assuming that all members of a culture or ethnic group are alike. Option 2 describes prejudice. Prejudice is a negative belief or preference that is generalized about a group, which leads to prejudgment. Prejudice occurs when the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Discussing the clients health status with family members is not stereotypical behavior and would be considered a violation of the privacy laws if the client did not provide permission for disclosure of personal health information.

D) Options 1, 2, 3, and 4 describe stereotypical behavior, which is assuming that all members of a culture or ethnic group are alike. Option 2 describes prejudice. Prejudice is a negative belief or preference that is generalized about a group, which leads to prejudgment. Prejudice occurs when the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Discussing the clients health status with family members is not stereotypical behavior and would be considered a violation of the privacy laws if the client did not provide permission for disclosure of personal health information.

Copyright 2015 Pearson Education, Inc.

E) Options 1, 2, 3, and 4 describe stereotypical behavior, which is assuming that all members of a culture or ethnic group are alike. Option 2 describes prejudice. Prejudice is a negative belief or preference that is generalized about a group, which leads to prejudgment. Prejudice occurs when the person making the judgment generalizes an experience of one individual from a culture to all members of that group. Discussing the clients health status with family members is not stereotypical behavior and would be considered a violation of the privacy laws if the client did not provide permission for disclosure of personal health information.

Page Ref: 15

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across the life span for individuals with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

4) The nurse is caring for a client who has been admitted with persistent diarrhea lasting 3 days. Which of the following are appropriate nursing diagnoses for this client during the acute phase of the illness?

Select all that apply.

A) Decreased Cardiac Output

B) Ineffective Airway Clearance

C) Deficient Fluid Volume

D) Knowledge Deficit

E) Risk for Injury

Answer: A, E

Explanation: A) Metabolic acidosis affects cardiac output by decreasing contractility, slowing the heart rate, and increasing the risk for dysrhythmias. Appropriate nursing diagnoses during the acute phase of illness are Risk for Injury and Decreased Cardiac Output. The client may have a knowledge deficit but this is not an appropriate nursing diagnosis during the acute phase of the illness. The client with metabolic acidosis will be at risk for developing an Excessive Fluid Volume, not a Deficient Fluid Volume. The client with metabolic acidosis is not at risk for Ineffective Airway Clearance.

B) Metabolic acidosis affects cardiac output by decreasing contractility, slowing the heart rate, and increasing the risk for dysrhythmias. Appropriate nursing diagnoses during the acute phase of illness are Risk for Injury and Decreased Cardiac Output. The client may have a knowledge deficit but this is not an appropriate nursing diagnosis during the acute phase of the illness. The client with metabolic acidosis will be at risk for developing an Excessive Fluid Volume, not a Deficient Fluid Volume. The client with metabolic acidosis is not at risk for Ineffective Airway Clearance.

C) Metabolic acidosis affects cardiac output by decreasing contractility, slowing the heart rate, and increasing the risk for dysrhythmias. Appropriate nursing diagnoses during the acute phase of illness are Risk for Injury and Decreased Cardiac Output. The client may have a knowledge deficit but this is not an appropriate nursing diagnosis during the acute phase of the illness. The client with metabolic acidosis will be at risk for developing an Excessive Fluid Volume, not a Deficient Fluid Volume. The client with metabolic acidosis is not at risk for Ineffective Airway Clearance.

D) Metabolic acidosis affects cardiac output by decreasing contractility, slowing the heart rate, and increasing the risk for dysrhythmias. Appropriate nursing diagnoses during the acute phase of illness are Risk for Injury and Decreased Cardiac Output. The client may have a knowledge deficit but this is not an appropriate nursing diagnosis during the acute phase of the illness. The client with metabolic acidosis will be at risk for developing an Excessive Fluid Volume, not a Deficient Fluid Volume. The client with metabolic acidosis is not at risk for Ineffective Airway Clearance.

Copyright 2015 Pearson Education, Inc.

E) Metabolic acidosis affects cardiac output by decreasing contractility, slowing the heart rate, and increasing the risk for dysrhythmias. Appropriate nursing diagnoses during the acute phase of illness are Risk for Injury and Decreased Cardiac Output. The client may have a knowledge deficit but this is not an appropriate nursing diagnosis during the acute phase of the illness. The client with metabolic acidosis will be at risk for developing an Excessive Fluid Volume, not a Deficient Fluid Volume. The client with metabolic acidosis is not at risk for Ineffective Airway Clearance.

Page Ref: 15

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

5) The nurse is caring for a client with metabolic acidosis. Which of the following are appropriate goals for this client?

Select all that apply.

A) The client will maintain a respiratory rate of 30 or more.

B) The client will describe preventative measure for the underlying chronic illness.

C) The client will maintain baseline cardiac rhythm.

D) pH will range from 7.25 to 7.35.

E) The client will take potassium supplements to increase potassium levels.

Answer: B, C

Explanation: A) Planning for the client with metabolic acidosis involves identification and treatment of the underlying cause and restoration and maintenance of acid-base balance. The client should be able to describe preventative measures for the underlying chronic illness that caused the metabolic acidosis to occur and maintain the baseline cardiac rhythm. The pH should be maintained between 7.35 and 7.45. The clients respiratory rate should be within normal range for age and condition. Taking a potassium supplement may cause hyperkalemia, which decreases cardiac output and worsens metabolic acidosis.

B) Planning for the client with metabolic acidosis involves identification and treatment of the underlying cause and restoration and maintenance of acid-base balance. The client should be able to describe preventative measures for the underlying chronic illness that caused the metabolic acidosis to occur and maintain the baseline cardiac rhythm. The pH should be maintained between 7.35 and 7.45. The clients respiratory rate should be within normal range for age and condition. Taking a potassium supplement may cause hyperkalemia, which decreases cardiac output and worsens metabolic acidosis.

C) Planning for the client with metabolic acidosis involves identification and treatment of the underlying cause and restoration and maintenance of acid-base balance. The client should be able to describe preventative measures for the underlying chronic illness that caused the metabolic acidosis to occur and maintain the baseline cardiac rhythm. The pH should be maintained between 7.35 and 7.45. The clients respiratory rate should be within normal range for age and condition. Taking a potassium supplement may cause hyperkalemia, which decreases cardiac output and worsens metabolic acidosis.

D) Planning for the client with metabolic acidosis involves identification and treatment of the underlying cause and restoration and maintenance of acid-base balance. The client should be able to describe preventative measures for the underlying chronic illness that caused the metabolic acidosis to occur and maintain the baseline cardiac rhythm. The pH should be maintained between 7.35 and 7.45. The clients respiratory rate should be within normal range for age and condition. Taking a potassium supplement may cause hyperkalemia, which decreases cardiac output and worsens metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

E) Planning for the client with metabolic acidosis involves identification and treatment of the underlying cause and restoration and maintenance of acid-base balance. The client should be able to describe preventative measures for the underlying chronic illness that caused the metabolic acidosis to occur and maintain the baseline cardiac rhythm. The pH should be maintained between 7.35 and 7.45. The clients respiratory rate should be within normal range for age and condition. Taking a potassium supplement may cause hyperkalemia, which decreases cardiac output and worsens metabolic acidosis.

Page Ref: 15-16

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with metabolic acidosis and his or her family in collaboration with other members of the healthcare team.

6) The nurse is caring for a client admitted with renal failure and metabolic acidosis. Which of the following signs would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective?

A) Decreased respiratory depth

B) Palpitations

C) Increased deep tendon reflexes

D) Respiratory rate of 38

Answer: A

Explanation: A) The client with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations. An increased respiratory rate, as indicated by a respiratory rate of 38, would indicate continued metabolic acidosis. Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis.

B) The client with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations. An increased respiratory rate, as indicated by a respiratory rate of 38, would indicate continued metabolic acidosis. Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis.

C) The client with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations. An increased respiratory rate, as indicated by a respiratory rate of 38, would indicate continued metabolic acidosis. Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis.

D) The client with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations. An increased respiratory rate, as indicated by a respiratory rate of 38, would indicate continued metabolic acidosis. Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis.

Page Ref: 15

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 7. Evaluate expected outcomes for an individual with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

7) The nurse is caring for the client experiencing hypovolemic shock and metabolic acidosis. Which of the following therapies would the nurse question if planned for this client?

Select all that apply.

A) Monitor weight on admission and discharge.

B) Monitor ECG for conduction problems.

C) Limit the intake of fluids.

D) Administer sodium bicarbonate.

E) Keep the bed in the locked and low position.

Answer: A, C

Explanation: A) The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. Patients being treated for hypovolemia will require daily weights, not a weight on admission and then discharge. Administering sodium bicarbonate and monitoring ECGs are appropriate for the client with shock. The client recovering from hypovolemic shock is at risk for injury, so the bed should be kept in the locked and low position.

B) The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. Patients being treated for hypovolemia will require daily weights, not a weight on admission and then discharge. Administering sodium bicarbonate and monitoring ECGs are appropriate for the client with shock. The client recovering from hypovolemic shock is at risk for injury, so the bed should be kept in the locked and low position.

C) The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. Patients being treated for hypovolemia will require daily weights, not a weight on admission and then discharge. Administering sodium bicarbonate and monitoring ECGs are appropriate for the client with shock. The client recovering from hypovolemic shock is at risk for injury, so the bed should be kept in the locked and low position.

D) The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. Patients being treated for hypovolemia will require daily weights, not a weight on admission and then discharge. Administering sodium bicarbonate and monitoring ECGs are appropriate for the client with shock. The client recovering from hypovolemic shock is at risk for injury, so the bed should be kept in the locked and low position.

E) The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. Patients being treated for hypovolemia will require daily weights, not a weight on admission and then discharge. Administering sodium bicarbonate and monitoring ECGs are appropriate for the client with shock. The client recovering from hypovolemic shock is at risk for injury, so the bed should be kept in the locked and low position.

Page Ref: 16

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

8) A client with metabolic acidosis has been admitted to the unit from the Emergency Department. The client is experiencing confusion and weakness. Which of the following does the nurse implement as a priority of care for this client?

A) Place the client in a high-Fowlers position.

B) Protect the client from injury.

C) Administer sodium bicarbonate.

D) Give the client skin care.

Answer: B

Explanation: A) The client with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury to the client. Medication administration is a physician order. Skin care would not be a priority on admission. The high-Fowlers position would not be the safest position for the confused client.

B) The client with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury to the client. Medication administration is a physician order. Skin care would not be a priority on admission. The high-Fowlers position would not be the safest position for the confused client.

C) The client with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury to the client. Medication administration is a physician order. Skin care would not be a priority on admission. The high-Fowlers position would not be the safest position for the confused client.

D) The client with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury to the client. Medication administration is a physician order. Skin care would not be a priority on admission. The high-Fowlers position would not be the safest position for the confused client.

Page Ref: 16

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with metabolic acidosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

9) The nurse is preparing to instruct a client with type 1 diabetes mellitus on the mechanism behind the development of ketoacidosis. List the order in which the nurse should provide this information.

1. Production of lactate and hydrogen ions

2. Development of lactic acidosis

3. Breakdown of fatty tissue

4. Reduction in intracellular glucose

5. Fatty acids converted to ketones

Answer: 2, 1, 4, 3, 5

Explanation:

1. Lactic acidosis develops due to tissue hypoxia and a shift to anaerobic metabolism by the cells. Lactate and hydrogen ions are produced, forming lactic acid. Starvation or lack of insulin leads to intracellular starvation of glucose. The lack of glucose or insulin to move glucose into the cells causes the body to break down fatty tissue to meet metabolic needs. When fatty acids are broken down, these acids are converted to ketones, leading to the development of ketoacidosis.

2. Lactic acidosis develops due to tissue hypoxia and a shift to anaerobic metabolism by the cells. Lactate and hydrogen ions are produced, forming lactic acid. Starvation or lack of insulin leads to intracellular starvation of glucose. The lack of glucose or insulin to move glucose into the cells causes the body to break down fatty tissue to meet metabolic needs. When fatty acids are broken down, these acids are converted to ketones, leading to the development of ketoacidosis.

3. Lactic acidosis develops due to tissue hypoxia and a shift to anaerobic metabolism by the cells. Lactate and hydrogen ions are produced, forming lactic acid. Starvation or lack of insulin leads to intracellular starvation of glucose. The lack of glucose or insulin to move glucose into the cells causes the body to break down fatty tissue to meet metabolic needs. When fatty acids are broken down, these acids are converted to ketones, leading to the development of ketoacidosis.

4. Lactic acidosis develops due to tissue hypoxia and a shift to anaerobic metabolism by the cells. Lactate and hydrogen ions are produced, forming lactic acid. Starvation or lack of insulin leads to intracellular starvation of glucose. The lack of glucose or insulin to move glucose into the cells causes the body to break down fatty tissue to meet metabolic needs. When fatty acids are broken down, these acids are converted to ketones, leading to the development of ketoacidosis.

5. Lactic acidosis develops due to tissue hypoxia and a shift to anaerobic metabolism by the cells. Lactate and hydrogen ions are produced, forming lactic acid. Starvation or lack of insulin leads to intracellular starvation of glucose. The lack of glucose or insulin to move glucose into the cells causes the body to break down fatty tissue to meet metabolic needs. When fatty acids are broken down, these acids are converted to ketones, leading to the development of ketoacidosis.

Page Ref: 14

Cognitive Level: Evaluating

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

10) The nurse is reviewing orders written by the healthcare provider for a client with metabolic acidosis. Which order should the nurse question before implementing it for the client?

A) Begin intravenous infusion of 0.9% normal saline.

B) Draw serum potassium levels every 2 hours.

C) Draw arterial blood gas samples every 2 hours.

D) Administer 1 ampule of sodium bicarbonate now.

Answer: D

Explanation: A) Administering bicarbonate to correct acidosis increases the risk for hypernatremia, hyperosmolality, and fluid volume excess. This is the order that the nurse should question before providing. Treatment of metabolic acidosis includes correction of fluid balance. An infusion of normal saline would be appropriate for this client. As metabolic acidosis is corrected, potassium shifts back into the intracellular space. This shift can lead to hypokalemia and cardiac dysrhythmias. Serum potassium levels should be carefully monitored during treatment. Arterial blood gases are used to evaluate treatment and guide additional therapies.

B) Administering bicarbonate to correct acidosis increases the risk for hypernatremia, hyperosmolality, and fluid volume excess. This is the order that the nurse should question before providing. Treatment of metabolic acidosis includes correction of fluid balance. An infusion of normal saline would be appropriate for this client. As metabolic acidosis is corrected, potassium shifts back into the intracellular space. This shift can lead to hypokalemia and cardiac dysrhythmias. Serum potassium levels should be carefully monitored during treatment. Arterial blood gases are used to evaluate treatment and guide additional therapies.

C) Administering bicarbonate to correct acidosis increases the risk for hypernatremia, hyperosmolality, and fluid volume excess. This is the order that the nurse should question before providing. Treatment of metabolic acidosis includes correction of fluid balance. An infusion of normal saline would be appropriate for this client. As metabolic acidosis is corrected, potassium shifts back into the intracellular space. This shift can lead to hypokalemia and cardiac dysrhythmias. Serum potassium levels should be carefully monitored during treatment. Arterial blood gases are used to evaluate treatment and guide additional therapies.

D) Administering bicarbonate to correct acidosis increases the risk for hypernatremia, hyperosmolality, and fluid volume excess. This is the order that the nurse should question before providing. Treatment of metabolic acidosis includes correction of fluid balance. An infusion of normal saline would be appropriate for this client. As metabolic acidosis is corrected, potassium shifts back into the intracellular space. This shift can lead to hypokalemia and cardiac dysrhythmias. Serum potassium levels should be carefully monitored during treatment. Arterial blood gases are used to evaluate treatment and guide additional therapies.

Page Ref: 12

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

11) The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis?

Select all that apply.

A) Apply wrist restraints and secure to the bed frame.

B) Discuss chemical restraint use with the healthcare provider.

C) Keep the bed in the lowest position.

D) Keep bed side rails raised.

E) Place a clock and calendar at the bedside.

Answer: C, D, E

Explanation: A) To reduce the clients risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a Risk for Injury is not a reason to use wrist or chemical restraints.

B) To reduce the clients risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a Risk for Injury is not a reason to use wrist or chemical restraints.

C) To reduce the clients risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a Risk for Injury is not a reason to use wrist or chemical restraints.

D) To reduce the clients risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a Risk for Injury is not a reason to use wrist or chemical restraints.

E) To reduce the clients risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a Risk for Injury is not a reason to use wrist or chemical restraints.

Page Ref: 16

Cognitive Level: Evaluating

Client Need: Safe and Effective Care Environment

Nursing Process: Planning

Learning Outcome: 6. Plan evidence-based care for an individual with metabolic acidosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

12) Upon entering a room, the nurse quickly scans the environment and then immediately assesses the client for manifestations of metabolic acidosis. What observation did the nurse make that precipitated this assessment of the client?

A) Client sleeping with the head of the bed flat

B) Half of the clients lunch tray uneaten

C) One formed stool in the bedside commode

D) 1000 mL of intravenous 0.9% normal saline infused in 2 hours

Answer: D

Explanation: A) Excessive infusions of chloride-containing intravenous fluids can precipitate metabolic acidosis. The head of the beds being flat might influence a clients oxygenation status; however, the client was not demonstrating a change in respiratory depth or rate. A reduction in oral intake does not cause metabolic acidosis. Eating half of a meal tray is not the same as starvation. Diarrhea can lead to the development of metabolic acidosis. One formed stool would not cause the nurse alarm.

B) Excessive infusions of chloride-containing intravenous fluids can precipitate metabolic acidosis. The head of the beds being flat might influence a clients oxygenation status; however, the client was not demonstrating a change in respiratory depth or rate. A reduction in oral intake does not cause metabolic acidosis. Eating half of a meal tray is not the same as starvation. Diarrhea can lead to the development of metabolic acidosis. One formed stool would not cause the nurse alarm.

C) Excessive infusions of chloride-containing intravenous fluids can precipitate metabolic acidosis. The head of the beds being flat might influence a clients oxygenation status; however, the client was not demonstrating a change in respiratory depth or rate. A reduction in oral intake does not cause metabolic acidosis. Eating half of a meal tray is not the same as starvation. Diarrhea can lead to the development of metabolic acidosis. One formed stool would not cause the nurse alarm.

D) Excessive infusions of chloride-containing intravenous fluids can precipitate metabolic acidosis. The head of the beds being flat might influence a clients oxygenation status; however, the client was not demonstrating a change in respiratory depth or rate. A reduction in oral intake does not cause metabolic acidosis. Eating half of a meal tray is not the same as starvation. Diarrhea can lead to the development of metabolic acidosis. One formed stool would not cause the nurse alarm.

Page Ref: 9

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 2. Identify risk factors and prevention methods associated with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

13) During a home visit, the nurse evaluates care provided to a client with type 1 diabetes mellitus and a history of metabolic acidosis. Which outcome indicates that the care of this client has been successful?

A) The client is injecting insulin into thigh muscle.

B) The client is taking laxatives three times a week to ensure adequate bowel movements.

C) The client is eating three balanced meals per day with two snacks.

D) The client is taking aspirin 325 mg every 6 hours to treat arthritis pain.

Answer: C

Explanation: A) Adequate nutrition is necessary to prevent the buildup of acids in the blood. Incorrect administration of medication could cause a metabolic problem in the client with diabetes. The use of laxatives could cause diarrhea, which can lead to metabolic acidosis. Ingestion of high amounts of salicylate acid can lead to toxicity and the development of metabolic acidosis.

B) Adequate nutrition is necessary to prevent the buildup of acids in the blood. Incorrect administration of medication could cause a metabolic problem in the client with diabetes. The use of laxatives could cause diarrhea, which can lead to metabolic acidosis. Ingestion of high amounts of salicylate acid can lead to toxicity and the development of metabolic acidosis.

C) Adequate nutrition is necessary to prevent the buildup of acids in the blood. Incorrect administration of medication could cause a metabolic problem in the client with diabetes. The use of laxatives could cause diarrhea, which can lead to metabolic acidosis. Ingestion of high amounts of salicylate acid can lead to toxicity and the development of metabolic acidosis.

D) Adequate nutrition is necessary to prevent the buildup of acids in the blood. Incorrect administration of medication could cause a metabolic problem in the client with diabetes. The use of laxatives could cause diarrhea, which can lead to metabolic acidosis. Ingestion of high amounts of salicylate acid can lead to toxicity and the development of metabolic acidosis.

Page Ref: 16

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Evaluation

Learning Outcome: 7. Evaluate expected outcomes for an individual with metabolic acidosis.

Copyright 2015 Pearson Education, Inc.

Exemplar 1.2 Metabolic Alkalosis

1) The client has been vomiting for several days. The nurse knows that the client is at risk for metabolic alkalosis because gastric secretions have which of the following characteristics?

A) Gastric secretions are green in color.

B) Gastric secretions are alkaline.

C) Gastric secretions are acidic.

D) Gastric secretions have a foul smell.

Answer: C

Explanation: A) Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost through vomiting or gastric suction, the alkalinity of body fluids increases. This increased alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys as chloride is depleted. Gastric secretions are now alkaline. The color and odor of gastric secretions have no influence on the development of metabolic acidosis.

B) Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost through vomiting or gastric suction, the alkalinity of body fluids increases. This increased alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys as chloride is depleted. Gastric secretions are now alkaline. The color and odor of gastric secretions have no influence on the development of metabolic acidosis.

C) Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost through vomiting or gastric suction, the alkalinity of body fluids increases. This increased alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys as chloride is depleted. Gastric secretions are now alkaline. The color and odor of gastric secretions have no influence on the development of metabolic acidosis.

D) Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost through vomiting or gastric suction, the alkalinity of body fluids increases. This increased alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys as chloride is depleted. Gastric secretions are now alkaline. The color and odor of gastric secretions have no influence on the development of metabolic acidosis.

Page Ref: 17

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of metabolic alkalosis.

Copyright 2015 Pearson Education, Inc.

2) The nurse is caring for a client who has been admitted to the hospital for congestive heart failure. Which data collected during the nursing assessment indicates that the client is at risk for metabolic alkalosis?

Select all that apply.

A) The client takes furosemide (Lasix) daily.

B) The client takes a baby aspirin once daily.

C) The client takes metformin daily.

D) The client frequently uses calcium carbonate (Tums) for acid indigestion.

E) The client takes acetaminophen as needed for pain.

Answer: A, D

Explanation: A) Excessive use of calcium carbonate and daily use of furosemide can cause metabolic alkalosis. Use of metformin is not associated with alkalosis. Overuse of aspirin can be associated with metabolic acidosis. Occasional use of acetaminophen is not associated with metabolic alkalosis.

B) Excessive use of calcium carbonate and daily use of furosemide can cause metabolic alkalosis. Use of metformin is not associated with alkalosis. Overuse of aspirin can be associated with metabolic acidosis. Occasional use of acetaminophen is not associated with metabolic alkalosis.

C) Excessive use of calcium carbonate and daily use of furosemide can cause metabolic alkalosis. Use of metformin is not associated with alkalosis. Overuse of aspirin can be associated with metabolic acidosis. Occasional use of acetaminophen is not associated with metabolic alkalosis.

D) Excessive use of calcium carbonate and daily use of furosemide can cause metabolic alkalosis. Use of metformin is not associated with alkalosis. Overuse of aspirin can be associated with metabolic acidosis. Occasional use of acetaminophen is not associated with metabolic alkalosis.

E) Excessive use of calcium carbonate and daily use of furosemide can cause metabolic alkalosis. Use of metformin is not associated with alkalosis. Overuse of aspirin can be associated with metabolic acidosis. Occasional use of acetaminophen is not associated with metabolic alkalosis.

Page Ref: 18

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with metabolic alkalosis.

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3) An Asian-American adolescent is hospitalized following several days of vomiting following food poisoning. The nurse is planning to include which points when teaching the clients family at discharge?

Select all that apply.

A) Immunizations for the adolescent

B) Nutritional patterns of the adolescent

C) Signs and symptoms of metabolic alkalosis

D) Proper food-handling techniques

E) Normal laboratory values of the adolescent

Answer: C, D

Explanation: A) The family of anyone experiencing prolonged vomiting should be taught the signs and symptoms of metabolic alkalosis. In this case, the nurse would include teaching about proper methods of food handling to prevent further episodes of food poisoning. Food patterns of the adolescent are not the precipitating factor of the food poisoning, and immunizations would not prevent this disease. Unless the family asks, it is not necessary to teach normal laboratory findings.

B) The family of anyone experiencing prolonged vomiting should be taught the signs and symptoms of metabolic alkalosis. In this case, the nurse would include teaching about proper methods of food handling to prevent further episodes of food poisoning. Food patterns of the adolescent are not the precipitating factor of the food poisoning, and immunizations would not prevent this disease. Unless the family asks, it is not necessary to teach normal laboratory findings.

C) The family of anyone experiencing prolonged vomiting should be taught the signs and symptoms of metabolic alkalosis. In this case, the nurse would include teaching about proper methods of food handling to prevent further episodes of food poisoning. Food patterns of the adolescent are not the precipitating factor of the food poisoning, and immunizations would not prevent this disease. Unless the family asks, it is not necessary to teach normal laboratory findings.

D) The family of anyone experiencing prolonged vomiting should be taught the signs and symptoms of metabolic alkalosis. In this case, the nurse would include teaching about proper methods of food handling to prevent further episodes of food poisoning. Food patterns of the adolescent are not the precipitating factor of the food poisoning, and immunizations would not prevent this disease. Unless the family asks, it is not necessary to teach normal laboratory findings.

E) The family of anyone experiencing prolonged vomiting should be taught the signs and symptoms of metabolic alkalosis. In this case, the nurse would include teaching about proper methods of food handling to prevent further episodes of food poisoning. Food patterns of the adolescent are not the precipitating factor of the food poisoning, and immunizations would not prevent this disease. Unless the family asks, it is not necessary to teach normal laboratory findings.

Page Ref: 1

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across the life span for individuals with metabolic alkalosis.

4) The nurse is planning care for the client who has been admitted with metabolic alkalosis. Which are appropriate nursing diagnoses for this client during the acute phase of the illness?

Select all that apply.

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A) Ineffective Health Maintenance

B) Risk for Hypothermia

C) Deficient Fluid Volume

D) Risk for Impaired Gas Exchange

E) Risk for Injury

Answer: C, D, E

Explanation: A) Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations, leading to the retention of carbon dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis. The client is at risk for injury because of the associated muscle spasms and dizziness.

B) Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations, leading to the retention of carbon dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis. The client is at risk for injury because of the associated muscle spasms and dizziness.

C) Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations, leading to the retention of carbon dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis. The client is at risk for injury because of the associated muscle spasms and dizziness.

D) Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations, leading to the retention of carbon dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis. The client is at risk for injury because of the associated muscle spasms and dizziness.

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E) Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations, leading to the retention of carbon dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis. The client is at risk for injury because of the associated muscle spasms and dizziness.

Page Ref: 19

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with metabolic alkalosis.

5) The nurse is planning care for the client with Cushings syndrome who has been admitted for complications related to the disease process. Which intervention should the nurse plan for this client to improve the impaired gas exchange?

A) Monitor serum electrolytes.

B) Schedule nursing activities to allow for periods of rest.

C) Assess input and output accurately.

D) Administer IV fluids per practitioner order.

Answer: B

Explanation: A) The client with Cushings syndrome is at risk for developing severe metabolic alkalosis that causes hypoxemia and limits energy reserves. Spacing nursing activities throughout the day allows the client ample rest time. The other interventions are aimed at the deficient fluid volume that may occur with metabolic alkalosis.

B) The client with Cushings syndrome is at risk for developing severe metabolic alkalosis that causes hypoxemia and limits energy reserves. Spacing nursing activities throughout the day allows the client ample rest time. The other interventions are aimed at the deficient fluid volume that may occur with metabolic alkalosis.

C) The client with Cushings syndrome is at risk for developing severe metabolic alkalosis that causes hypoxemia and limits energy reserves. Spacing nursing activities throughout the day allows the client ample rest time. The other interventions are aimed at the deficient fluid volume that may occur with metabolic alkalosis.

D) The client with Cushings syndrome is at risk for developing severe metabolic alkalosis that causes hypoxemia and limits energy reserves. Spacing nursing activities throughout the day allows the client ample rest time. The other interventions are aimed at the deficient fluid volume that may occur with metabolic alkalosis.

Page Ref: 19

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with metabolic alkalosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

Copyright 2015 Pearson Education, Inc.

6) The nurse is preparing to discharge a client with congestive heart failure on furosemide (Lasix). The nurse determines that teaching has been effective if the client makes which statement?

A) I will use only sodium bicarbonate as my antacid.

B) I will restrict my intake of fluids.

C) I will use potassium supplements while I am taking Lasix.

D) I will take antacids only for my gastric discomforts.

Answer: C

Explanation: A) The client on Lasix (furosemide) may lose excess potassium, disposing the client toward metabolic alkalosis. The client is taught to refrain from the use of sodium antacids when prone to metabolic alkalosis. The client should consult with the primary care provider for gastric distress rather than self-medicate. The client who is prone to metabolic alkalosis is likely to have fluid deficits and would not be instructed to restrict fluids.

B) The client on Lasix (furosemide) may lose excess potassium, disposing the client toward metabolic alkalosis. The client is taught to refrain from the use of sodium antacids when prone to metabolic alkalosis. The client should consult with the primary care provider for gastric distress rather than self-medicate. The client who is prone to metabolic alkalosis is likely to have fluid deficits and would not be instructed to restrict fluids.

C) The client on Lasix (furosemide) may lose excess potassium, disposing the client toward metabolic alkalosis. The client is taught to refrain from the use of sodium antacids when prone to metabolic alkalosis. The client should consult with the primary care provider for gastric distress rather than self-medicate. The client who is prone to metabolic alkalosis is likely to have fluid deficits and would not be instructed to restrict fluids.

D) The client on Lasix (furosemide) may lose excess potassium, disposing the client toward metabolic alkalosis. The client is taught to refrain from the use of sodium antacids when prone to metabolic alkalosis. The client should consult with the primary care provider for gastric distress rather than self-medicate. The client who is prone to metabolic alkalosis is likely to have fluid deficits and would not be instructed to restrict fluids.

Page Ref: 16

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 7. Evaluate expected outcomes for an individual with metabolic alkalosis.

Copyright 2015 Pearson Education, Inc.

7) A client with severe metabolic alkalosis has been admitted to the unit and is being cared for by a nursing student along with the nurse. What should the nurse say is a priority for this client?

A) Administering medication for metabolic alkalosis

B) Monitoring oxygen saturation

C) Teaching the client the risk factors for metabolic alkalosis

D) Setting goals for the client with metabolic alkalosis

Answer: B

Explanation: A) The priority for this client is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues. Administering medications will be needed as a treatment, but the priority is to discover the cause. Teaching the client and setting goals are important aspects of nursing care but are not the priority.

B) The priority for this client is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues. Administering medications will be needed as a treatment, but the priority is to discover the cause. Teaching the client and setting goals are important aspects of nursing care but are not the priority.

C) The priority for this client is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues. Administering medications will be needed as a treatment, but the priority is to discover the cause. Teaching the client and setting goals are important aspects of nursing care but are not the priority.

D) The priority for this client is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues. Administering medications will be needed as a treatment, but the priority is to discover the cause. Teaching the client and setting goals are important aspects of nursing care but are not the priority.

Page Ref: 19

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with metabolic alkalosis.

Copyright 2015 Pearson Education, Inc.

8) A client with hyperaldosteronism has been admitted to the unit. The nurse knows the client is at risk for impaired gas exchange. Which position should this client be placed to enhance gas exchange?

A) Fowlers position

B) Prone position

C) Left side-lying position

D) Right Sims position

Answer: A

Explanation: A) The client with prolonged vomiting will likely have severe metabolic alkalosis with reduced oxygenation. The Fowlers position will facilitate alveolar ventilation with improved oxygenation. Side-lying and prone positions do not facilitate needed lung expansion.

B) The client with prolonged vomiting will likely have severe metabolic alkalosis with reduced oxygenation. The Fowlers position will facilitate alveolar ventilation with improved oxygenation. Side-lying and prone positions do not facilitate needed lung expansion.

C) The client with prolonged vomiting will likely have severe metabolic alkalosis with reduced oxygenation. The Fowlers position will facilitate alveolar ventilation with improved oxygenation. Side-lying and prone positions do not facilitate needed lung expansion.

D) The client with prolonged vomiting will likely have severe metabolic alkalosis with reduced oxygenation. The Fowlers position will facilitate alveolar ventilation with improved oxygenation. Side-lying and prone positions do not facilitate needed lung expansion.

Page Ref: 19

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with metabolic alkalosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

9) While reviewing laboratory results, the nurse notes that a clients potassium level is 2.8 mEq/L and chloride level is 100 mEq/L. How should the nurse plan to support this clients acid-base balance?

A) Prepare to administer 0.9% sodium chloride infusion.

B) Measure for nasogastric tube insertion.

C) Discuss potassium chloride replace therapy with the healthcare provider.

D) Review implications of transfusing with ammonia chloride.

Answer: C

Explanation: A) Treatment of metabolic alkalosis includes restoring normal fluid volume and administering potassium chloride. The potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions more effectively. Since the chloride level is within normal limits, an infusion of 0.9% sodium chloride is not indicated. Removal of gastric secretions is one reason for the development of metabolic alkalosis. A nasogastric tube is not indicated for this client. There is not enough information to support the use of ammonia chloride for this client, as it is indicated to treat severe metabolic alkalosis.

B) Treatment of metabolic alkalosis includes restoring normal fluid volume and administering potassium chloride. The potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions more effectively. Since the chloride level is within normal limits, an infusion of 0.9% sodium chloride is not indicated. Removal of gastric secretions is one reason for the development of metabolic alkalosis. A nasogastric tube is not indicated for this client. There is not enough information to support the use of ammonia chloride for this client, as it is indicated to treat severe metabolic alkalosis.

C) Treatment of metabolic alkalosis includes restoring normal fluid volume and administering potassium chloride. The potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions more effectively. Since the chloride level is within normal limits, an infusion of 0.9% sodium chloride is not indicated. Removal of gastric secretions is one reason for the development of metabolic alkalosis. A nasogastric tube is not indicated for this client. There is not enough information to support the use of ammonia chloride for this client, as it is indicated to treat severe metabolic alkalosis.

D) Treatment of metabolic alkalosis includes restoring normal fluid volume and administering potassium chloride. The potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions more effectively. Since the chloride level is within normal limits, an infusion of 0.9% sodium chloride is not indicated. Removal of gastric secretions is one reason for the development of metabolic alkalosis. A nasogastric tube is not indicated for this client. There is not enough information to support the use of ammonia chloride for this client, as it is indicated to treat severe metabolic alkalosis.

Page Ref: 18

Cognitive Level: Evaluating

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 6. Plan evidence-based care for an individual with metabolic alkalosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

10) The nurse identifies the diagnosis Risk for Impaired Gas Exchange to guide the care of a client with metabolic alkalosis. What did the nurse assess to support this diagnosis?

Select all that apply.

A) Respiratory rate 8 per minute

B) Oxygen saturation 89%

C) Urine output 25 mL/hr

D) Restlessness and agitation

E) Weight loss of 3 kg overnight

Answer: A, B, D

Explanation: A) Respiratory compensation for metabolic alkalosis depresses the respiratory rate and reduces the depth of breathing to promote carbon dioxide retention. The depressed respiratory drive associated with metabolic alkalosis can lead to hypoxemia and impaired oxygenation of tissues. Oxygen saturation levels of less than 90% indicate significant oxygenation problems. Changes in mental status or behavior may be early signs of hypoxia. Urine output less than 30 mL/hr would indicate Fluid Volume Deficit. Weight is used as an indicator of fluid balance. A rapid weight change would indicate Fluid Volume Deficit.

B) Respiratory compensation for metabolic alkalosis depresses the respiratory rate and reduces the depth of breathing to promote carbon dioxide retention. The depressed respiratory drive associated with metabolic alkalosis can lead to hypoxemia and impaired oxygenation of tissues. Oxygen saturation levels of less than 90% indicate significant oxygenation problems. Changes in mental status or behavior may be early signs of hypoxia. Urine output less than 30 mL/hr would indicate Fluid Volume Deficit. Weight is used as an indicator of fluid balance. A rapid weight change would indicate Fluid Volume Deficit.

C) Respiratory compensation for metabolic alkalosis depresses the respiratory rate and reduces the depth of breathing to promote carbon dioxide retention. The depressed respiratory drive associated with metabolic alkalosis can lead to hypoxemia and impaired oxygenation of tissues. Oxygen saturation levels of less than 90% indicate significant oxygenation problems. Changes in mental status or behavior may be early signs of hypoxia. Urine output less than 30 mL/hr would indicate Fluid Volume Deficit. Weight is used as an indicator of fluid balance. A rapid weight change would indicate Fluid Volume Deficit.

D) Respiratory compensation for metabolic alkalosis depresses the respiratory rate and reduces the depth of breathing to promote carbon dioxide retention. The depressed respiratory drive associated with metabolic alkalosis can lead to hypoxemia and impaired oxygenation of tissues. Oxygen saturation levels of less than 90% indicate significant oxygenation problems. Changes in mental status or behavior may be early signs of hypoxia. Urine output less than 30 mL/hr would indicate Fluid Volume Deficit. Weight is used as an indicator of fluid balance. A rapid weight change would indicate Fluid Volume Deficit.

Copyright 2015 Pearson Education, Inc.

E) Respiratory compensation for metabolic alkalosis depresses the respiratory rate and reduces the depth of breathing to promote carbon dioxide retention. The depressed respiratory drive associated with metabolic alkalosis can lead to hypoxemia and impaired oxygenation of tissues. Oxygen saturation levels of less than 90% indicate significant oxygenation problems. Changes in mental status or behavior may be early signs of hypoxia. Urine output less than 30 mL/hr would indicate Fluid Volume Deficit. Weight is used as an indicator of fluid balance. A rapid weight change would indicate Fluid Volume Deficit.

Page Ref: 19

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with metabolic alkalosis.

Copyright 2015 Pearson Education, Inc.

11) A client is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings should the nurse suspect will confirm this diagnosis?

Select all that apply.

A) Serum glucose level 142 mg/dL

B) Blood pH 7.47 and bicarbonate 34 mEq/L

C) Intravenous pyelogram shows kidney stones

D) Bilateral lower lobe infiltrates noted on chest x-ray

E) Electrocardiogram changes consistent with hypokalemia

Answer: B, E

Explanation: A) In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 28 mEq/L. The ECG pattern shows changes similar to those seen with hypokalemia. Serum glucose level is not used to confirm the diagnosis of metabolic alkalosis. The presence of kidney stones is not associated with the development of metabolic alkalosis. The presence of bilateral lower lobe infiltrates on chest x-ray would not contribute to the development of metabolic alkalosis. This finding might be the result of metabolic alkalosis if the clients respiratory status is compromised.

B) In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 28 mEq/L. The ECG pattern shows changes similar to those seen with hypokalemia. Serum glucose level is not used to confirm the diagnosis of metabolic alkalosis. The presence of kidney stones is not associated with the development of metabolic alkalosis. The presence of bilateral lower lobe infiltrates on chest x-ray would not contribute to the development of metabolic alkalosis. This finding might be the result of metabolic alkalosis if the clients respiratory status is compromised.

C) In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 28 mEq/L. The ECG pattern shows changes similar to those seen with hypokalemia. Serum glucose level is not used to confirm the diagnosis of metabolic alkalosis. The presence of kidney stones is not associated with the development of metabolic alkalosis. The presence of bilateral lower lobe infiltrates on chest x-ray would not contribute to the development of metabolic alkalosis. This finding might be the result of metabolic alkalosis if the clients respiratory status is compromised.

D) In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 28 mEq/L. The ECG pattern shows changes similar to those seen with hypokalemia. Serum glucose level is not used to confirm the diagnosis of metabolic alkalosis. The presence of kidney stones is not associated with the development of metabolic alkalosis. The presence of bilateral lower lobe infiltrates on chest x-ray would not contribute to the development of metabolic alkalosis. This finding might be the result of metabolic alkalosis if the clients respiratory status is compromised.

Copyright 2015 Pearson Education, Inc.

E) In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 28 mEq/L. The ECG pattern shows changes similar to those seen with hypokalemia. Serum glucose level is not used to confirm the diagnosis of metabolic alkalosis. The presence of kidney stones is not associated with the development of metabolic alkalosis. The presence of bilateral lower lobe infiltrates on chest x-ray would not contribute to the development of metabolic alkalosis. This finding might be the result of metabolic alkalosis if the clients respiratory status is compromised.

Page Ref: 18

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with metabolic alkalosis.

12) During an assessment, the nurse becomes concerned that a client is at risk for developing metabolic alkalosis. What did the nurse assess that caused this concern?

A) Daily ingestion of a banana with breakfast

B) Daily weight consistent

C) Daily use of sodium bicarbonate for gastric upset

D) Daily use of prescribed NSAIDs for arthritic pain

Answer: C

Explanation: A) Excess bicarbonate usually occurs as a result of ingesting antacids that contain bicarbonate, such as soda bicarbonate or Alka-SeltzerTM. Daily ingestion of a banana would prevent the development of hypokalemia from the daily use of sodium bicarbonate. Consistent daily weights would indicate fluid balance. Daily use of NSAIDs would not support the development of metabolic alkalosis.

B) Excess bicarbonate usually occurs as a result of ingesting antacids that contain bicarbonate, such as soda bicarbonate or Alka-SeltzerTM. Daily ingestion of a banana would prevent the development of hypokalemia from the daily use of sodium bicarbonate. Consistent daily weights would indicate fluid balance. Daily use of NSAIDs would not support the development of metabolic alkalosis.

C) Excess bicarbonate usually occurs as a result of ingesting antacids that contain bicarbonate, such as soda bicarbonate or Alka-SeltzerTM. Daily ingestion of a banana would prevent the development of hypokalemia from the daily use of sodium bicarbonate. Consistent daily weights would indicate fluid balance. Daily use of NSAIDs would not support the development of metabolic alkalosis.

D) Excess bicarbonate usually occurs as a result of ingesting antacids that contain bicarbonate, such as soda bicarbonate or Alka-SeltzerTM. Daily ingestion of a banana would prevent the development of hypokalemia from the daily use of sodium bicarbonate. Consistent daily weights would indicate fluid balance. Daily use of NSAIDs would not support the development of metabolic alkalosis.

Page Ref: 18

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 2. Identify risk factors and prevention methods associated with metabolic alkalosis.

Copyright 2015 Pearson Education, Inc.

13) During a home visit, the nurse evaluates teaching provided to a client recently hospitalized for metabolic alkalosis. Which observation indicates that additional teaching is required?

A) Drinks 2 cups of black coffee each day.

B) Consumes one orange each day with breakfast.

C) Ingests bicarbonate of soda after each meal.

D) Monitors and tracks daily weights.

Answer: C

Explanation: A) The indiscriminate ingestion of sodium bicarbonate is a risk factor for the development of metabolic alkalosis. Black coffee is not associated with the development of metabolic alkalosis. Oranges contain potassium, which is beneficial to prevent the development of metabolic alkalosis. Tracking of daily weights would help detect a fluid imbalance, which is associated with metabolic alkalosis.

B) The indiscriminate ingestion of sodium bicarbonate is a risk factor for the development of metabolic alkalosis. Black coffee is not associated with the development of metabolic alkalosis. Oranges contain potassium, which is beneficial to prevent the development of metabolic alkalosis. Tracking of daily weights would help detect a fluid imbalance, which is associated with metabolic alkalosis.

C) The indiscriminate ingestion of sodium bicarbonate is a risk factor for the development of metabolic alkalosis. Black coffee is not associated with the development of metabolic alkalosis. Oranges contain potassium, which is beneficial to prevent the development of metabolic alkalosis. Tracking of daily weights would help detect a fluid imbalance, which is associated with metabolic alkalosis.

D) The indiscriminate ingestion of sodium bicarbonate is a risk factor for the development of metabolic alkalosis. Black coffee is not associated with the development of metabolic alkalosis. Oranges contain potassium, which is beneficial to prevent the development of metabolic alkalosis. Tracking of daily weights would help detect a fluid imbalance, which is associated with metabolic alkalosis.

Page Ref: 20

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 7. Evaluate expected outcomes for an individual with metabolic alkalosis.

Copyright 2015 Pearson Education, Inc.

Exemplar 1.3 Respiratory Acidosis

1) The nurse has admitted a client who was brought to the hospital after a morphine overdose. What acid-base imbalance does the nurse expect to observe in this client?

A) Respiratory alkalosis

B) Respiratory acidosis

C) Metabolic alkalosis

D) Metabolic acidosis

Answer: B

Explanation: A) Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this client is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this clients morphine overdose.

B) Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this client is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this clients morphine overdose.

C) Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this client is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this clients morphine overdose.

D) Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this client is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this clients morphine overdose.

Page Ref: 21

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

2) The nurse is caring for a client who has been admitted to the unit with respiratory failure and respiratory acidosis. What data from the nursing history would the nurse suspect contributed to the clients current state of health?

A) Use of ibuprofen for the control of pain

B) A recent trip to South America

C) Aspiration pneumonia

D) Recent recovery from a cold virus

Answer: C

Explanation: A) Aspiration of a foreign body and acute pneumonia would put the client at risk for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk factor. Recent recovery from a cold would not likely put the client at risk. Ibuprofen does not pose a threat to the respiratory health of the client.

B) Aspiration of a foreign body and acute pneumonia would put the client at risk for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk factor. Recent recovery from a cold would not likely put the client at risk. Ibuprofen does not pose a threat to the respiratory health of the client.

C) Aspiration of a foreign body and acute pneumonia would put the client at risk for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk factor. Recent recovery from a cold would not likely put the client at risk. Ibuprofen does not pose a threat to the respiratory health of the client.

D) Aspiration of a foreign body and acute pneumonia would put the client at risk for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk factor. Recent recovery from a cold would not likely put the client at risk. Ibuprofen does not pose a threat to the respiratory health of the client.

Page Ref: 9

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

3) A 10-year-old boy has been admitted to the hospital with respiratory acidosis. The nurse suspects that which chronic lung disease most likely caused the child to develop this condition?

A) Cystic fibrosis

B) Aspiration

C) Hyperthyroidism

D) Pneumonia

Answer: A

Explanation: A) Chronic lung disease such as asthma and cystic fibrosis put the child at risk for respiratory acidosis. Pneumonia and aspiration are both acute lung conditions. Hyperthyroidism is a disorder that results in metabolic acidosis.

B) Chronic lung disease such as asthma and cystic fibrosis put the child at risk for respiratory acidosis. Pneumonia and aspiration are both acute lung conditions. Hyperthyroidism is a disorder that results in metabolic acidosis.

C) Chronic lung disease such as asthma and cystic fibrosis put the child at risk for respiratory acidosis. Pneumonia and aspiration are both acute lung conditions. Hyperthyroidism is a disorder that results in metabolic acidosis.

D) Chronic lung disease such as asthma and cystic fibrosis put the child at risk for respiratory acidosis. Pneumonia and aspiration are both acute lung conditions. Hyperthyroidism is a disorder that results in metabolic acidosis.

Page Ref: 9

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across the life span for individuals with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

4) A client has been admitted to the unit with chronic obstructive pulmonary disease. Blood gas analysis indicates respiratory acidosis. The nurse anticipates which diagnosis should be the priority for this client?

A) Impaired Gas Exchange

B) Ineffective Airway Clearance

C) Impaired Mobility

D) Anxiety

Answer: A

Explanation: A) Impaired Gas Exchange is the priority nursing diagnosis for the client with respiratory acidosis. Interventions are aimed at restoring effective alveolar ventilation and gas exchange. Anxiety and Ineffective Airway Clearance are both appropriate nursing diagnoses but not priority for the client with respiratory acidosis. There is no evidence to support Impaired Mobility for this client.

B) Impaired Gas Exchange is the priority nursing diagnosis for the client with respiratory acidosis. Interventions are aimed at restoring effective alveolar ventilation and gas exchange. Anxiety and Ineffective Airway Clearance are both appropriate nursing diagnoses but not priority for the client with respiratory acidosis. There is no evidence to support Impaired Mobility for this client.

C) Impaired Gas Exchange is the priority nursing diagnosis for the client with respiratory acidosis. Interventions are aimed at restoring effective alveolar ventilation and gas exchange. Anxiety and Ineffective Airway Clearance are both appropriate nursing diagnoses but not priority for the client with respiratory acidosis. There is no evidence to support Impaired Mobility for this client.

D) Impaired Gas Exchange is the priority nursing diagnosis for the client with respiratory acidosis. Interventions are aimed at restoring effective alveolar ventilation and gas exchange. Anxiety and Ineffective Airway Clearance are both appropriate nursing diagnoses but not priority for the client with respiratory acidosis. There is no evidence to support Impaired Mobility for this client.

Page Ref: 23

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

5) The nurse is preparing discharge instructions for an older client recovering from respiratory acidosis caused by restrictive lung disease and pneumonia. What should the nurse include in this teaching?

Select all that apply.

A) Obtain annual influenza immunization.

B) Engage in frequent hand washing.

C) Avoid crowds.

D) Cover the nose and mouth when coughing.

E) Restrict fluids.

Answer: A, B, C, D

Explanation: A) For the client with a history of chronic lung disease and pneumonia, the nurse should instruct on the importance of receiving annual influenza immunizations, frequent hand washing, avoiding crowds, and covering the nose and mouth when coughing. Fluids should be encouraged to ensure that respiratory secretions are thin.

B) For the client with a history of chronic lung disease and pneumonia, the nurse should instruct on the importance of receiving annual influenza immunizations, frequent hand washing, avoiding crowds, and covering the nose and mouth when coughing. Fluids should be encouraged to ensure that respiratory secretions are thin.

C) For the client with a history of chronic lung disease and pneumonia, the nurse should instruct on the importance of receiving annual influenza immunizations, frequent hand washing, avoiding crowds, and covering the nose and mouth when coughing. Fluids should be encouraged to ensure that respiratory secretions are thin.

D) For the client with a history of chronic lung disease and pneumonia, the nurse should instruct on the importance of receiving annual influenza immunizations, frequent hand washing, avoiding crowds, and covering the nose and mouth when coughing. Fluids should be encouraged to ensure that respiratory secretions are thin.

E) For the client with a history of chronic lung disease and pneumonia, the nurse should instruct on the importance of receiving annual influenza immunizations, frequent hand washing, avoiding crowds, and covering the nose and mouth when coughing. Fluids should be encouraged to ensure that respiratory secretions are thin.

Page Ref: 24

Cognitive Level: Evaluating

Client Need: Health Promotion and Maintenance

Nursing Process: Implementation/Teaching and Learning

Learning Outcome: 6. Plan evidence-based care for an individual with respiratory acidosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

6) The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals a pH of 7.20 and a PaCO2 of 49 mmHg. Which change in ventilator settings should the nurse anticipate?

A) Increase in humidification of inspired air

B) Decrease of FiO2 from 30% to 25%

C) Increased respiratory rate to 30 breaths per minute

D) Decreased tidal volume of each breath

Answer: C

Explanation: A) This client is exhibiting respiratory acidosis. This client needs to blow off more CO2; therefore, the respiratory rate would be increased. No other option given would serve to decrease CO2 levels.

B) This client is exhibiting respiratory acidosis. This client needs to blow off more CO2; therefore, the respiratory rate would be increased. No other option given would serve to decrease CO2 levels.

C) This client is exhibiting respiratory acidosis. This client needs to blow off more CO2; therefore, the respiratory rate would be increased. No other option given would serve to decrease CO2 levels.

D) This client is exhibiting respiratory acidosis. This client needs to blow off more CO2; therefore, the respiratory rate would be increased. No other option given would serve to decrease CO2 levels.

Page Ref: 22

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 7. Evaluate expected outcomes for an individual with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

7) The nurse is preparing to admit a client with acute pneumonia who is experiencing severe respiratory acidosis. The nurse anticipates that treatment for this client may include which actions?

Select all that apply.

A) Administer oxygen prn.

B) Administer digoxin for heart failure.

C) Encourage up to 3L of fluids per day.

D) Place in a prone position.

E) Reposition frequently.

Answer: A, C, E

Explanation: A) The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia.

B) The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia.

C) The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia.

D) The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia.

E) The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia.

Page Ref: 23

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

8) The nurse is providing care to a client recently extubated for treatment of aspiration pneumonia and respiratory acidosis. Which action by the nurse provides an optimum environment for this client?

A) Allowing family members to remain with client as much as possible

B) Restraining the client

C) Placing the client in a side-lying position

D) Administering narcotics for pain

Answer: A

Explanation: A) The client with respiratory acidosis often experiences anxiety. This client would benefit from having a family member in the room to provide reassurance. Restraining the client will increase levels of agitation. The client with respiratory failure would benefit most from the semi-Fowlers or Fowlers position to increase ventilation. Narcotics will depress the respirations and increase respiratory acidosis. A non-narcotic pain reliever would be considered if this client were experiencing pain.

B) The client with respiratory acidosis often experiences anxiety. This client would benefit from having a family member in the room to provide reassurance. Restraining the client will increase levels of agitation. The client with respiratory failure would benefit most from the semi-Fowlers or Fowlers position to increase ventilation. Narcotics will depress the respirations and increase respiratory acidosis. A non-narcotic pain reliever would be considered if this client were experiencing pain.

C) The client with respiratory acidosis often experiences anxiety. This client would benefit from having a family member in the room to provide reassurance. Restraining the client will increase levels of agitation. The client with respiratory failure would benefit most from the semi-Fowlers or Fowlers position to increase ventilation. Narcotics will depress the respirations and increase respiratory acidosis. A non-narcotic pain reliever would be considered if this client were experiencing pain.

D) The client with respiratory acidosis often experiences anxiety. This client would benefit from having a family member in the room to provide reassurance. Restraining the client will increase levels of agitation. The client with respiratory failure would benefit most from the semi-Fowlers or Fowlers position to increase ventilation. Narcotics will depress the respirations and increase respiratory acidosis. A non-narcotic pain reliever would be considered if this client were experiencing pain.

Page Ref: 23

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with respiratory acidosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

9) The nurse is reviewing orders written for a client with chronic respiratory acidosis. Which order should the nurse question before implementing for this client?

A) Keep head of the bed elevated to 40-degree angle.

B) Dextrose 5% and 0.45% normal saline at 100 mL per hour

C) Consult Respiratory Therapy for breathing treatments four times a day.

D) Oxygen 4 liters per nasal cannula

Answer: D

Explanation: A) In clients with chronic respiratory acidosis, oxygen is administered cautiously to prevent carbon dioxide narcosis. Adequate hydration such as intravenous fluids is important to promote removal of respiratory secretions. Pulmonary hygiene measures such as breathing treatments may be instituted.

B) In clients with chronic respiratory acidosis, oxygen is administered cautiously to prevent carbon dioxide narcosis. Adequate hydration such as intravenous fluids is important to promote removal of respiratory secretions. Pulmonary hygiene measures such as breathing treatments may be instituted.

C) In clients with chronic respiratory acidosis, oxygen is administered cautiously to prevent carbon dioxide narcosis. Adequate hydration such as intravenous fluids is important to promote removal of respiratory secretions. Pulmonary hygiene measures such as breathing treatments may be instituted.

D) In clients with chronic respiratory acidosis, oxygen is administered cautiously to prevent carbon dioxide narcosis. Adequate hydration such as intravenous fluids is important to promote removal of respiratory secretions. Pulmonary hygiene measures such as breathing treatments may be instituted.

Page Ref: 23

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 6. Plan evidence-based care for an individual with respiratory acidosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

10) A client with pneumonia develops respiratory acidosis. Which medications should the nurse prepare to administer to this client?

Select all that apply.

A) Furosemide (Lasix) 20 mg by mouth twice a day

B) Amoxicillin 1 gram intravenous every 6 hours

C) Albuterol inhaler 2 puffs every 4 hours

D) Diazepam (Valium) 2 mg by mouth at bedtime for sleep

E) Potassium chloride 20 mEq in 100 mL 0.9% normal saline intravenous every day

Answer: B, C

Explanation: A) Bronchodilator drugs such as albuterol inhaler may be administered to open the airways and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this clients respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.

B) Bronchodilator drugs such as albuterol inhaler may be administered to open the airways and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this clients respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.

C) Bronchodilator drugs such as albuterol inhaler may be administered to open the airways and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this clients respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.

D) Bronchodilator drugs such as albuterol inhaler may be administered to open the airways and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this clients respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.

E) Bronchodilator drugs such as albuterol inhaler may be administered to open the airways and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this clients respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.

Page Ref: 22

Cognitive Level: Evaluating

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

11) A client brought to the Emergency Department for treatment of an overdose has arterial blood gas results that indicate acute respiratory acidosis. For which substance should the nurse plan care for this client?

A) Cocaine

B) Marijuana

C) Oxycodone

D) PCP

Answer: C

Explanation: A) Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can lead to respiratory depression and respiratory acidosis. Cocaine is a stimulant. Marijuana is not considered as a drug that depresses the central nervous system or respiratory center. PCP is a hallucinogenic agent.

B) Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can lead to respiratory depression and respiratory acidosis. Cocaine is a stimulant. Marijuana is not considered as a drug that depresses the central nervous system or respiratory center. PCP is a hallucinogenic agent.

C) Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can lead to respiratory depression and respiratory acidosis. Cocaine is a stimulant. Marijuana is not considered as a drug that depresses the central nervous system or respiratory center. PCP is a hallucinogenic agent.

D) Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can lead to respiratory depression and respiratory acidosis. Cocaine is a stimulant. Marijuana is not considered as a drug that depresses the central nervous system or respiratory center. PCP is a hallucinogenic agent.

Page Ref: 21

Cognitive Level: Evaluating

Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 2. Identify risk factors and prevention methods associated with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

12) The nurse suspects a client with one functioning lung is developing chronic respiratory acidosis. Which manifestation did the nurse most likely assess in this client?

A) Warm, flushed skin

B) Daytime sleepiness

C) Irritability

D) Blurred vision

Answer: B

Explanation: A) The manifestations of acute and chronic respiratory acidosis differ. The client with chronic respiratory acidosis will demonstrate daytime sleepiness. The client with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation.

B) The manifestations of acute and chronic respiratory acidosis differ. The client with chronic respiratory acidosis will demonstrate daytime sleepiness. The client with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation.

C) The manifestations of acute and chronic respiratory acidosis differ. The client with chronic respiratory acidosis will demonstrate daytime sleepiness. The client with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation.

D) The manifestations of acute and chronic respiratory acidosis differ. The client with chronic respiratory acidosis will demonstrate daytime sleepiness. The client with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation.

Page Ref: 21

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

13) The nurse instructs a client with a history of acute respiratory acidosis and lung infections on ways to prevent further episodes of the health problem. Which client statement indicates that teaching has been effective?

A) I will limit drinking alcohol to the evening hours only.

B) I will limit my intake of bananas and oranges.

C) I will take prescribed antibiotics until my symptoms subside.

D) I will receive the annual influenza vaccination.

Answer: D

Explanation: A) The nurse should discuss ways to avoid future episodes of acute respiratory infections by encouraging the client to receive immunization against pneumococcal pneumonia and influenza. Alcohol is a central nervous system depressant which can adversely affect respiratory status and lead to the development of respiratory acidosis. The ingestion of bananas and oranges will not promote the development of respiratory acidosis. The client should be instructed to complete a full course of antibiotics prescribed to treat infections.

B) The nurse should discuss ways to avoid future episodes of acute respiratory infections by encouraging the client to receive immunization against pneumococcal pneumonia and influenza. Alcohol is a central nervous system depressant which can adversely affect respiratory status and lead to the development of respiratory acidosis. The ingestion of bananas and oranges will not promote the development of respiratory acidosis. The client should be instructed to complete a full course of antibiotics prescribed to treat infections.

C) The nurse should discuss ways to avoid future episodes of acute respiratory infections by encouraging the client to receive immunization against pneumococcal pneumonia and influenza. Alcohol is a central nervous system depressant which can adversely affect respiratory status and lead to the development of respiratory acidosis. The ingestion of bananas and oranges will not promote the development of respiratory acidosis. The client should be instructed to complete a full course of antibiotics prescribed to treat infections.

D) The nurse should discuss ways to avoid future episodes of acute respiratory infections by encouraging the client to receive immunization against pneumococcal pneumonia and influenza. Alcohol is a central nervous system depressant which can adversely affect respiratory status and lead to the development of respiratory acidosis. The ingestion of bananas and oranges will not promote the development of respiratory acidosis. The client should be instructed to complete a full course of antibiotics prescribed to treat infections.

Page Ref: 24

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 7. Evaluate expected outcomes for an individual with respiratory acidosis.

Copyright 2015 Pearson Education, Inc.

Exemplar 1.4 Respiratory Alkalosis

1) A client is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas value should the nurse expect with respiratory alkalosis?

A) pH is 7.33 and PaCO2 is 36.

B) pH is 7.30 and HCO3 is 30.

C) pH is 7.47 and PaCO2 is 25.

D) pH is 7.35 and PaO2 is 88.

Answer: C

Explanation: A) Acute pain usually causes hyperventilation, which causes the CO2 to drop and the client to experience respiratory alkalosis. The pH would denote alkalosis and would be higher than 7.45. HCO3 would trend downwards as the kidneys begin to compensate for the alkalosis by excreting HCO3. The PaO2 is likely to be normal unless the client has been hyperventilating for a long time and is beginning to tire.

B) Acute pain usually causes hyperventilation, which causes the CO2 to drop and the client to experience respiratory alkalosis. The pH would denote alkalosis and would be higher than 7.45. HCO3 would trend downwards as the kidneys begin to compensate for the alkalosis by excreting HCO3. The PaO2 is likely to be normal unless the client has been hyperventilating for a long time and is beginning to tire.

C) Acute pain usually causes hyperventilation, which causes the CO2 to drop and the client to experience respiratory alkalosis. The pH would denote alkalosis and would be higher than 7.45. HCO3 would trend downwards as the kidneys begin to compensate for the alkalosis by excreting HCO3. The PaO2 is likely to be normal unless the client has been hyperventilating for a long time and is beginning to tire.

D) Acute pain usually causes hyperventilation, which causes the CO2 to drop and the client to experience respiratory alkalosis. The pH would denote alkalosis and would be higher than 7.45. HCO3 would trend downwards as the kidneys begin to compensate for the alkalosis by excreting HCO3. The PaO2 is likely to be normal unless the client has been hyperventilating for a long time and is beginning to tire.

Page Ref: 25

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of respiratory alkalosis.

Copyright 2015 Pearson Education, Inc.

2) The client is seen in the Emergency Department with symptoms of a panic attack, including hyperventilation. The nurse suspects that the client may be at risk for which health problem on admission?

A) Hypoventilation

B) Vomiting

C) Respiratory alkalosis

D) Memory loss

Answer: C

Explanation: A) Anxiety disorders increase the risk for the acid-base imbalance respiratory alkalosis, due to hyperventilation that accompanies anxiety and panic attacks. The client with anxiety does not necessarily have vomiting or memory loss as risk factors. Anxiety and panic attacks will lead to hyperventilation, not hypoventilation.

B) Anxiety disorders increase the risk for the acid-base imbalance respiratory alkalosis, due to hyperventilation that accompanies anxiety and panic attacks. The client with anxiety does not necessarily have vomiting or memory loss as risk factors. Anxiety and panic attacks will lead to hyperventilation, not hypoventilation.

C) Anxiety disorders increase the risk for the acid-base imbalance respiratory alkalosis, due to hyperventilation that accompanies anxiety and panic attacks. The client with anxiety does not necessarily have vomiting or memory loss as risk factors. Anxiety and panic attacks will lead to hyperventilation, not hypoventilation.

D) Anxiety disorders increase the risk for the acid-base imbalance respiratory alkalosis, due to hyperventilation that accompanies anxiety and panic attacks. The client with anxiety does not necessarily have vomiting or memory loss as risk factors. Anxiety and panic attacks will lead to hyperventilation, not hypoventilation.

Page Ref: 25

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with respiratory alkalosis.

Copyright 2015 Pearson Education, Inc.

3) The nurse, caring for a Jewish client with respiratory alkalosis, tells another nurse that Jewish families are so hard to deal with; all they do is complain. What behavior is the nurse demonstrating?

A) Culture shock

B) Discrimination

C) Prejudice

D) Stereotyping

Answer: D

Explanation: A) The nurse is exhibiting stereotyping by assuming that all members of a culture or ethnic group are alike. Culture shock is a disorder that occurs in response to transition from one cultural setting to another. Prejudice is a negative belief or preconceived opinion that is not based on reason or actual experience. Discrimination occurs when a person acts on prejudice and denies another person one or more of the fundamental rights.

B) The nurse is exhibiting stereotyping by assuming that all members of a culture or ethnic group are alike. Culture shock is a disorder that occurs in response to transition from one cultural setting to another. Prejudice is a negative belief or preconceived opinion that is not based on reason or actual experience. Discrimination occurs when a person acts on prejudice and denies another person one or more of the fundamental rights.

C) The nurse is exhibiting stereotyping by assuming that all members of a culture or ethnic group are alike. Culture shock is a disorder that occurs in response to transition from one cultural setting to another. Prejudice is a negative belief or preconceived opinion that is not based on reason or actual experience. Discrimination occurs when a person acts on prejudice and denies another person one or more of the fundamental rights.

D) The nurse is exhibiting stereotyping by assuming that all members of a culture or ethnic group are alike. Culture shock is a disorder that occurs in response to transition from one cultural setting to another. Prejudice is a negative belief or preconceived opinion that is not based on reason or actual experience. Discrimination occurs when a person acts on prejudice and denies another person one or more of the fundamental rights.

Page Ref: 26

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across the life span for individuals with respiratory alkalosis.

Copyright 2015 Pearson Education, Inc.

4) The nurse is planning care for a client who has been admitted to the unit with a salicylate overdose. When preparing the plan of care, the nurse considers which to be a priority nursing diagnosis?

A) Ineffective Breathing Pattern

B) Powerlessness

C) Risk for Injury

D) Impaired Mobility

Answer: A

Explanation: A) The client with a salicylate overdose is at risk for hyperventilation, which can lead to respiratory alkalosis. There is not enough information to know whether the clients mobility is impaired. Risk for Injury and Powerlessness are diagnoses to be considered for this client, but the highest priority is respiratory function.

B) The client with a salicylate overdose is at risk for hyperventilation, which can lead to respiratory alkalosis. There is not enough information to know whether the clients mobility is impaired. Risk for Injury and Powerlessness are diagnoses to be considered for this client, but the highest priority is respiratory function.

C) The client with a salicylate overdose is at risk for hyperventilation, which can lead to respiratory alkalosis. There is not enough information to know whether the clients mobility is impaired. Risk for Injury and Powerlessness are diagnoses to be considered for this client, but the highest priority is respiratory function.

D) The client with a salicylate overdose is at risk for hyperventilation, which can lead to respiratory alkalosis. There is not enough information to know whether the clients mobility is impaired. Risk for Injury and Powerlessness are diagnoses to be considered for this client, but the highest priority is respiratory function.

Page Ref: 26

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with respiratory alkalosis.

Copyright 2015 Pearson Education, Inc.

5) The client with an anxiety disorder is ready to be discharged from the unit. What should the nurse plan to teach this client and family in preparation for discharge?

Select all that apply.

A) Refer the client for counseling.

B) Instruct the client to eat foods high in acid.

C) Teach the client the signs of impending panic attack.

D) Advise the client to breathe into a paper bag when feeling anxious.

E) Instruct the client to breathe slowly.

Answer: A, C, E

Explanation: A) Teaching the client to breathe slowly helps the client manage hyperventilation at home. The client with an anxiety disorder should be referred to counseling to assist with management of the disorder and should be taught signs of an impending panic attack. Eating foods high in acid will not counteract the results of hyperventilation. The use of paper bags has been a recommended treatment for hyperventilation; however, it can also cause hypoxia.

B) Teaching the client to breathe slowly helps the client manage hyperventilation at home. The client with an anxiety disorder should be referred to counseling to assist with management of the disorder and should be taught signs of an impending panic attack. Eating foods high in acid will not counteract the results of hyperventilation. The use of paper bags has been a recommended treatment for hyperventilation; however, it can also cause hypoxia.

C) Teaching the client to breathe slowly helps the client manage hyperventilation at home. The client with an anxiety disorder should be referred to counseling to assist with management of the disorder and should be taught signs of an impending panic attack. Eating foods high in acid will not counteract the results of hyperventilation. The use of paper bags has been a recommended treatment for hyperventilation; however, it can also cause hypoxia.

D) Teaching the client to breathe slowly helps the client manage hyperventilation at home. The client with an anxiety disorder should be referred to counseling to assist with management of the disorder and should be taught signs of an impending panic attack. Eating foods high in acid will not counteract the results of hyperventilation. The use of paper bags has been a recommended treatment for hyperventilation; however, it can also cause hypoxia.

E) Teaching the client to breathe slowly helps the client manage hyperventilation at home. The client with an anxiety disorder should be referred to counseling to assist with management of the disorder and should be taught signs of an impending panic attack. Eating foods high in acid will not counteract the results of hyperventilation. The use of paper bags has been a recommended treatment for hyperventilation; however, it can also cause hypoxia.

Page Ref: 26

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with respiratory alkalosis and his or her family in collaboration with other members of the healthcare team.

Copyright 2015 Pearson Education, Inc.

6) The nurse has completed discharge teaching for a client with an anxiety disorder. Which client statement indicates that client teaching about respiratory alkalosis has been effective?

A) I will see my counselor on a regular basis.

B) I will breather faster when I am feeling anxious.

C) I will eat more bananas at breakfast.

D) I will not take antacids when I have heartburn.

Answer: A

Explanation: A) The client understands that reducing anxiety can reduce hyperventilation and respiratory alkalosis. Seeing a counselor can help the client develop alternative strategies for dealing with anxiety. Eating bananas is more appropriate for the client at risk for metabolic alkalosis who is on diuretics. Breathing faster will increase hyperventilation. Taking too many antacids is associated with metabolic alkalosis.

B) The client understands that reducing anxiety can reduce hyperventilation and respiratory alkalosis. Seeing a counselor can help the client develop alternative strategies for dealing with anxiety. Eating bananas is more appropriate for the client at risk for metabolic alkalosis who is on diuretics. Breathing faster will increase hyperventilation. Taking too many antacids is associated with metabolic alkalosis.

C) The client understands that reducing anxiety can reduce hyperventilation and respiratory alkalosis. Seeing a counselor can help the client develop alternative strategies for dealing with anxiety. Eating bananas is more appropriate for the client at risk for metabolic alkalosis who is on diuretics. Breathing faster will increase hyperventilation. Taking too many antacids is associated with metabolic alkalosis.

D) The client understands that reducing anxiety can reduce hyperventilation and respiratory alkalosis. Seeing a counselor can help the client develop alternative strategies for dealing with anxiety. Eating bananas is more appropriate for the client at risk for metabolic alkalosis who is on diuretics. Breathing faster will increase hyperventilation. Taking too many antacids is associated with metabolic alkalosis.

Page Ref: 27

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 7. Evaluate expected outcomes for an individual with respiratory alkalosis.

Copyright 2015 Pearson Education, Inc.

7) The nurse is reviewing new orders written for a client experiencing respiratory alkalosis. Which orders would be appropriate for this clients care needs?

Select all that apply.

A) Oxygen 2 liters via face mask

B) Restrict fluids to 2 liters per day.

C) Admit to a private room.

D) Infuse 1 ampule of sodium bicarbonate now.

E) Draw arterial blood gases.

Answer: C, E

Explanation: A) The client has respiratory alkalosis, which is caused by hyperventilation. Additional oxygen is not required. A fluid restriction is not required in the treatment of respiratory alkalosis. Management of respiratory alkalosis focuses on correcting the imbalance and treating the underlying cause. It is important to create a calm, quiet, low-stimulation environment to reduce the clients anxiety or panic. Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis. Arterial blood gases must be ordered prior to beginning medication or oxygen therapy.

B) The client has respiratory alkalosis, which is caused by hyperventilation. Additional oxygen is not required. A fluid restriction is not required in the treatment of respiratory alkalosis. Management of respiratory alkalosis focuses on correcting the imbalance and treating the underlying cause. It is important to create a calm, quiet, low-stimulation environment to reduce the clients anxiety or panic. Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis. Arterial blood gases must be ordered prior to beginning medication or oxygen therapy.

C) The client has respiratory alkalosis, which is caused by hyperventilation. Additional oxygen is not required. A fluid restriction is not required in the treatment of respiratory alkalosis. Management of respiratory alkalosis focuses on correcting the imbalance and treating the underlying cause. It is important to create a calm, quiet, low-stimulation environment to reduce the clients anxiety or panic. Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis. Arterial blood gases must be ordered prior to beginning medication or oxygen therapy.

D) The client has respiratory alkalosis, which is caused by hyperventilation. Additional oxygen is not required. A fluid restriction is not required in the treatment of respiratory alkalosis. Management of respiratory alkalosis focuses on correcting the imbalance and treating the underlying cause. It is important to create a calm, quiet, low-stimulation environment to reduce the clients anxiety or panic. Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis. Arterial blood gases must be ordered prior to beginning medication or oxygen therapy.

Copyright 2015 Pearson Education, Inc.

E) The client has respiratory alkalosis, which is caused by hyperventilation. Additional oxygen is not required. A fluid restriction is not required in the treatment of respiratory alkalosis. Management of respiratory alkalosis focuses on correcting the imbalance and treating the underlying cause. It is important to create a calm, quiet, low-stimulation environment to reduce the clients anxiety or panic. Sodium bicarbonate is used in the treatment of respiratory and metabolic acidosis. Arterial blood gases must be ordered prior to beginning medication or oxygen therapy.

Page Ref: 26

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with respiratory alkalosis.

8) The nurse is caring for the client with a history of anxiety who is experiencing chest pain, palpitations and dyspnea. Which intervention would be a priority for this client?

A) Providing educational material for the clients medical diagnosis

B) Ordering a regular diet for the client

C) Reassuring the client that symptoms will resolve

D) Asking Respiratory Therapy to set up a mechanical ventilator

Answer: C

Explanation: A) The client will require reassurance from the nurse that the symptoms being experienced are not those of a heart attack and that the symptoms will resolve when a normal breathing pattern returns to normal. Ordering the diet and instructing the respiratory therapist are done by the healthcare provider. Providing teaching for the client becomes a priority when the client is recovering from the illness.

B) The client will require reassurance from the nurse that the symptoms being experienced are not those of a heart attack and that the symptoms will resolve when a normal breathing pattern returns to normal. Ordering the diet and instructing the respiratory therapist are done by the healthcare provider. Providing teaching for the client becomes a priority when the client is recovering from the illness.

C) The client will require reassurance from the nurse that the symptoms being experienced are not those of a heart attack and that the symptoms will resolve when a normal breathing pattern returns to normal. Ordering the diet and instructing the respiratory therapist are done by the healthcare provider. Providing teaching for the client becomes a priority when the client is recovering from the illness.

D) The client will require reassurance from the nurse that the symptoms being experienced are not those of a heart attack and that the symptoms will resolve when a normal breathing pattern returns to normal. Ordering the diet and instructing the respiratory therapist are done by the healthcare provider. Providing teaching for the client becomes a priority when the client is recovering from the illness.

Page Ref: 26

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with respiratory alkalosis and his or her family in collaboration with other members of the healthcare team.

9) A client with metabolic alkalosis is experiencing numbness around the mouth and tingling of the fingers. What should the nurse explain as the reason for these manifestations?

A) Because you are breathing so fast, the oxygen is not getting to your nerve endings.

B) Your health problem affects calcium in your body, which causes the tingling around your mouth and fingers.

C) You have a build-up of carbon dioxide in your blood.

D) You dont have enough potassium in your body, so the tingling around your mouth and fingers will occur.

Answer: B

Explanation: A) Alkalosis increases binding of extracellular calcium to albumin, reducing ionized calcium levels. As a result, neuromuscular excitability increases, and manifestations similar to hypocalcemia develop. These manifestations include circumoral and distal extremity paresthesias. Rapid breathing is not reducing the amount of oxygen reaching the nerve endings. Excessive carbon dioxide would lead to acidosis. Respiratory alkalosis is not caused by an imbalance of serum potassium.

B) Alkalosis increases binding of extracellular calcium to albumin, reducing ionized calcium levels. As a result, neuromuscular excitability increases, and manifestations similar to hypocalcemia develop. These manifestations include circumoral and distal extremity paresthesias. Rapid breathing is not reducing the amount of oxygen reaching the nerve endings. Excessive carbon dioxide would lead to acidosis. Respiratory alkalosis is not caused by an imbalance of serum potassium.

C) Alkalosis increases binding of extracellular calcium to albumin, reducing ionized calcium levels. As a result, neuromuscular excitability increases, and manifestations similar to hypocalcemia develop. These manifestations include circumoral and distal extremity paresthesias. Rapid breathing is not reducing the amount of oxygen reaching the nerve endings. Excessive carbon dioxide would lead to acidosis. Respiratory alkalosis is not caused by an imbalance of serum potassium.

D) Alkalosis increases binding of extracellular calcium to albumin, reducing ionized calcium levels. As a result, neuromuscular excitability increases, and manifestations similar to hypocalcemia develop. These manifestations include circumoral and distal extremity paresthesias. Rapid breathing is not reducing the amount of oxygen reaching the nerve endings. Excessive carbon dioxide would lead to acidosis. Respiratory alkalosis is not caused by an imbalance of serum potassium.

Page Ref: 18

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of respiratory alkalosis.

10) A client with injuries from a motor vehicle crash is intubated for respiratory support. The nurse notes that the client is fighting the ventilator and attempting to pull out the endotracheal tube. What should the nurse do to reduce this clients risk of developing respiratory alkalosis?

A) Administer a sedative as prescribed.

B) Apply wrist restraints.

C) Teach the client to take slow, deep breaths.

D) Discuss removing the endotracheal tube with the healthcare provider.

Answer: A

Explanation: A) For a client being mechanically ventilated, the only way to reduce rapid respirations might be to provide a sedative. Applying wrist restraints to a client who is demonstrating anxiety with an endotracheal tube might increase the clients anxiety. The client is being mechanically ventilated, which means there is a problem with maintaining the airway. The client will not be able to take slow, deep breaths at this time. The reason for the endotracheal tube is to maintain the clients airway after chest trauma. Removing the tube could lead to a collapse of the airway and a life-threatening situation.

B) For a client being mechanically ventilated, the only way to reduce rapid respirations might be to provide a sedative. Applying wrist restraints to a client who is demonstrating anxiety with an endotracheal tube might increase the clients anxiety. The client is being mechanically ventilated, which means there is a problem with maintaining the airway. The client will not be able to take slow, deep breaths at this time. The reason for the endotracheal tube is to maintain the clients airway after chest trauma. Removing the tube could lead to a collapse of the airway and a life-threatening situation.

C) For a client being mechanically ventilated, the only way to reduce rapid respirations might be to provide a sedative. Applying wrist restraints to a client who is demonstrating anxiety with an endotracheal tube might increase the clients anxiety. The client is being mechanically ventilated, which means there is a problem with maintaining the airway. The client will not be able to take slow, deep breaths at this time. The reason for the endotracheal tube is to maintain the clients airway after chest trauma. Removing the tube could lead to a collapse of the airway and a life-threatening situation.

D) For a client being mechanically ventilated, the only way to reduce rapid respirations might be to provide a sedative. Applying wrist restraints to a client who is demonstrating anxiety with an endotracheal tube might increase the clients anxiety. The client is being mechanically ventilated, which means there is a problem with maintaining the airway. The client will not be able to take slow, deep breaths at this time. The reason for the endotracheal tube is to maintain the clients airway after chest trauma. Removing the tube could lead to a collapse of the airway and a life-threatening situation.

Page Ref: 25

Cognitive Level: Applying

Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors and prevention methods associated with respiratory alkalosis.

11) The nurse is evaluating care provided to a client with respiratory alkalosis. Which outcomes indicate that nursing care has been effective for this client?

Select all that apply.

A) Respiratory rate 18 and regular

B) Sleeping through the night

C) Gait steady

D) Consistent body weight

E) Using prescribed bronchodilators

Answer: A, B, C, D

Explanation: A) Appropriate outcomes for the care of a client with respiratory alkalosis include normal respiratory rate and rhythm, no episodes of injuries, and maintenance of fluid balance. Ability to sleep through the night would indicate a reduction in anxiety, which is a risk factor for the development of respiratory alkalosis. Bronchodilators are not used to treat this acid-base imbalance.

B) Appropriate outcomes for the care of a client with respiratory alkalosis include normal respiratory rate and rhythm, no episodes of injuries, and maintenance of fluid balance. Ability to sleep through the night would indicate a reduction in anxiety, which is a risk factor for the development of respiratory alkalosis. Bronchodilators are not used to treat this acid-base imbalance.

C) Appropriate outcomes for the care of a client with respiratory alkalosis include normal respiratory rate and rhythm, no episodes of injuries, and maintenance of fluid balance. Ability to sleep through the night would indicate a reduction in anxiety, which is a risk factor for the development of respiratory alkalosis. Bronchodilators are not used to treat this acid-base imbalance.

D) Appropriate outcomes for the care of a client with respiratory alkalosis include normal respiratory rate and rhythm, no episodes of injuries, and maintenance of fluid balance. Ability to sleep through the night would indicate a reduction in anxiety, which is a risk factor for the development of respiratory alkalosis. Bronchodilators are not used to treat this acid-base imbalance.

E) Appropriate outcomes for the care of a client with respiratory alkalosis include normal respiratory rate and rhythm, no episodes of injuries, and maintenance of fluid balance. Ability to sleep through the night would indicate a reduction in anxiety, which is a risk factor for the development of respiratory alkalosis. Bronchodilators are not used to treat this acid-base imbalance.

Page Ref: 27

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Nursing Process: Evaluation

Learning Outcome: 7. Evaluate expected outcomes for an individual with respiratory alkalosis.

12) A client is brought to the Emergency Department with rapid breathing after learning of a family member being killed in a house fire. What should the nurse do first to help this client?

A) Coach to slow the breathing.

B) Move to a quiet, calm environment.

C) Provide a sedative.

D) Ask for a psychiatric consultation.

Answer: B

Explanation: A) Nursing care is focused on reducing anxiety through manipulation of the environment to reduce stimuli and to create a sense of peace. This restful environment will help the client breathe more slowly and effectively. Once the environment is controlled, the nurse can begin to implement interventions to help the client slow the breathing rate. A sedative may be prescribed; however, this would not be the first intervention. A psychiatric consult might be indicated for someone with a history of anxiety or panic attacks that lead to the development of respiratory alkalosis. Since this client has had a shock, a psychiatric consultation would not be indicated at this time.

B) Nursing care is focused on reducing anxiety through manipulation of the environment to reduce stimuli and to create a sense of peace. This restful environment will help the client breathe more slowly and effectively. Once the environment is controlled, the nurse can begin to implement interventions to help the client slow the breathing rate. A sedative may be prescribed; however, this would not be the first intervention. A psychiatric consult might be indicated for someone with a history of anxiety or panic attacks that lead to the development of respiratory alkalosis. Since this client has had a shock, a psychiatric consultation would not be indicated at this time.

C) Nursing care is focused on reducing anxiety through manipulation of the environment to reduce stimuli and to create a sense of peace. This restful environment will help the client breathe more slowly and effectively. Once the environment is controlled, the nurse can begin to implement interventions to help the client slow the breathing rate. A sedative may be prescribed; however, this would not be the first intervention. A psychiatric consult might be indicated for someone with a history of anxiety or panic attacks that lead to the development of respiratory alkalosis. Since this client has had a shock, a psychiatric consultation would not be indicated at this time.

D) Nursing care is focused on reducing anxiety through manipulation of the environment to reduce stimuli and to create a sense of peace. This restful environment will help the client breathe more slowly and effectively. Once the environment is controlled, the nurse can begin to implement interventions to help the client slow the breathing rate. A sedative may be prescribed; however, this would not be the first intervention. A psychiatric consult might be indicated for someone with a history of anxiety or panic attacks that lead to the development of respiratory alkalosis. Since this client has had a shock, a psychiatric consultation would not be indicated at this time.

Page Ref: 25

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Nursing Process: Implementation

Learning Outcome: 6. Plan evidence-based care for an individual with respiratory alkalosis and his or her family in collaboration with other members of the healthcare team.

13) A client begins to hyperventilate after learning that a breast biopsy was positive for cancer. After a few minutes, the client loses consciousness. What should the nurse do?

A) Begin cardiopulmonary resuscitation.

B) Raise the side rails on the bed.

C) Notify the physician.

D) Insert an intravenous access device.

Answer: B

Explanation: A) The nurse should protect the client from injury. If hyperventilation continues to the point where the client loses consciousness, respirations will return to normal, as will acid-base balance. The nurse should ensure for the clients safety and raise the side rails on the bed. The client does not need cardiopulmonary resuscitation. The physician may need to be notified; however, the clients safety is a priority. The client is not critically ill and an intravenous access device is not indicated at this time.

B) The nurse should protect the client from injury. If hyperventilation continues to the point where the client loses consciousness, respirations will return to normal, as will acid-base balance. The nurse should ensure for the clients safety and raise the side rails on the bed. The client does not need cardiopulmonary resuscitation. The physician may need to be notified; however, the clients safety is a priority. The client is not critically ill and an intravenous access device is not indicated at this time.

C) The nurse should protect the client from injury. If hyperventilation continues to the point where the client loses consciousness, respirations will return to normal, as will acid-base balance. The nurse should ensure for the clients safety and raise the side rails on the bed. The client does not need cardiopulmonary resuscitation. The physician may need to be notified; however, the clients safety is a priority. The client is not critically ill and an intravenous access device is not indicated at this time.

D) The nurse should protect the client from injury. If hyperventilation continues to the point where the client loses consciousness, respirations will return to normal, as will acid-base balance. The nurse should ensure for the clients safety and raise the side rails on the bed. The client does not need cardiopulmonary resuscitation. The physician may need to be notified; however, the clients safety is a priority. The client is not critically ill and an intravenous access device is not indicated at this time.

Page Ref: 26

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Nursing Process: Implementation

Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across the life span for individuals with respiratory alkalosis.

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