A nurse admits an older adult to the ED and notes that the client is cyanotic and has a respiratory rate of 6 breaths/min. Which acid-base imbalance should the nurse associate with this finding?
respiratory acidosis
metabolic acidosis
respiratory alkalosis
metabolic alkalosis
The Correct Answer is A
Rationale:
A. Respiratory acidosis results from hypoventilation (respiratory rate of 6 breaths/min), leading to CO₂ retention and decreased blood pH. Cyanosis also indicates poor oxygenation, supporting this diagnosis.
B. Metabolic acidosis typically results from renal failure, diarrhea, or diabetic ketoacidosis, not directly from low respiratory rate.
C. Respiratory alkalosis is caused by hyperventilation, not hypoventilation.
D. Metabolic alkalosis is usually caused by vomiting or diuretic use and is not associated with decreased respiratory rate or cyanosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Rationale:
A. Magnesium plays a role in acid-base balance and influences potassium levels.
B. Sodium is important but less directly related to acid-base balance than potassium and magnesium.
C. Potassium is critical to monitor because acid-base imbalances often cause shifts in potassium levels, affecting cardiac function.
D. Calcium levels can be affected but are less immediately critical than potassium and magnesium.
E. Phosphate is involved in metabolism but is not a primary electrolyte monitored for acid-base balance.
Correct Answer is A
Explanation
Rationale:
A. Chvostek’s sign is a clinical indicator of hypocalcemia. It is elicited by tapping the facial nerve in front of the ear, which causes twitching of the facial muscles in clients with low calcium levels due to increased neuromuscular excitability.
B. Brudzinski’s sign indicates meningeal irritation, such as in meningitis, not hypocalcemia.
C. Cullen’s sign is bruising around the umbilicus, associated with intra-abdominal bleeding, not electrolyte imbalance.
D. Kernig’s sign is another sign of meningeal irritation and is unrelated to calcium levels.
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