A client is admitted to the medical-surgical unit with a chief complaint of prolonged vomiting over the past 24 hours. Based on the arterial blood gas (ABG) results of pH 7.5. PaCO2 36, HCO3 40, the nurse determines that the client is experiencing:
respiratory alkalosis.
respiratory acidosis.
metabolic acidosis.
metabolic alkalosis.
The Correct Answer is D
D. Metabolic alkalosis is characterized by an increased pH (alkalosis) and an increased HCO3. In this case, the pH is elevated (7.5), indicating alkalosis, which supports metabolic alkalosis. The HCO3 is elevated at 40 mEq/L, which further supports metabolic alkalosis. The PaCO2 is normal or slightly low (36 mmHg), which can occur as a compensatory response to metabolic alkalosis.
A. Respiratory alkalosis is characterized by an increase in pH (alkalosis) and a decrease in PaCO2 (hypocapnia). In this scenario, the pH is elevated (7.5), which indicates alkalosis. The PaCO2 is 36 mmHg, which is within the normal range (35-45 mmHg) but slightly on the lower side (slight hypocapnia). The HCO3 is elevated at 40 mEq/L, which suggests a compensatory response by the kidneys to retain bicarbonate to counteract the alkalosis.
B. Respiratory acidosis is characterized by a decrease in pH (acidosis) and an increase in PaCO2 (hypercapnia). In this case, the pH is elevated (7.5), indicating alkalosis, which contradicts respiratory acidosis. The PaCO2 is 36 mmHg, which is normal or slightly low, not high as expected in respiratory acidosis. The elevated HCO3 (40 mEq/L) suggests a compensatory metabolic response to the alkalosis, not to acidosis.
C. Metabolic acidosis is characterized by a decreased pH (acidosis) and a decreased HCO3. In this scenario, the pH is elevated (7.5), indicating alkalosis, which contradicts metabolic acidosis. The HCO3 is elevated at 40 mEq/L, indicating metabolic alkalosis rather than metabolic acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B. Temperature can significantly affect sleep quality. Ensuring the room is kept at a comfortable temperature (not too hot or cold) can promote better sleep. This intervention is appropriate.
C. Clean and dry bed linens contribute to comfort, which is essential for promoting sleep. This intervention is appropriate.
D. Discomfort can be a major barrier to sleep. Addressing any discomfort, such as pain, anxiety, or positioning issues, can help improve the client's ability to fall and stay asleep. This intervention is appropriate.
A. Offering chocolate, which contains caffeine, close to bedtime is not recommended as caffeine can interfere with sleep. Therefore, this option is not appropriate.
E. Moving the client closer to the nursing station may increase noise and disrupt sleep, especially if there are frequent activities or conversations near the nursing station. Therefore, this option is not typically recommended unless the client requires closer monitoring due to medical reasons.
Correct Answer is A
Explanation
A. Hyperkalemia can have significant cardiac effects, potentially leading to life-threatening arrhythmias such as bradycardia, heart block, ventricular tachycardia, or ventricular fibrillation. As potassium levels rise, it affects the electrical conduction of the heart, leading to changes in the ECG (electrocardiogram) and potentially causing fatal arrhythmias.
B. While hyperkalemia primarily affects the cardiovascular system, gastrointestinal symptoms can also occur. These may include nausea, vomiting, abdominal pain, and diarrhea. However, these symptoms are typically less severe compared to cardiac manifestations. Monitoring for gastrointestinal symptoms helps in assessing overall clinical status but is not as critical as assessing cardiac function in the context of hyperkalemia.
C. Respiratory symptoms are not typically associated with hyperkalemia unless severe acid-base disturbances are present. Potassium imbalance itself does not directly affect respiratory function. Therefore, while it is important to assess respiratory status in any client, it is not the priority in the context of hyperkalemia.
D. Hyperkalemia can affect the nervous system, leading to symptoms such as muscle weakness, tingling sensations, and even paralysis in severe cases. However, neurologic symptoms usually occur at higher potassium levels or in the presence of significant electrolyte imbalances affecting nerve function.
Monitoring for neurologic symptoms is important but is generally secondary to assessing cardiac status in the context of approaching severe hyperkalemia.
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