A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg PaCO2 33 mm Hg and HCO3-18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism?
Decreased urinary output
Increased respiratory rate
Peripheral edema
Hypertension
The Correct Answer is B
Rationale:
A. Decreased urinary output is not a compensatory response; it may indicate dehydration or renal dysfunction.
B. Increased respiratory rate is a compensatory mechanism. The low bicarbonate (HCO₃⁻ 18 mEq/L) indicates metabolic acidosis, and the body compensates by increasing ventilation to lower PaCO₂ and help normalize pH.
C. Peripheral edema is not a compensatory response to acid-base imbalance; it relates to fluid retention or cardiac issues.
D. Hypertension is unrelated to acid-base compensation; it may be present due to other comorbidities but is not a compensatory mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Wheezing is associated with airway obstruction (e.g., asthma or COPD), not pleural effusion.
B. Dullness to percussion is a classic finding in pleural effusion because fluid in the pleural space dampens the sound produced during percussion.
C. Increased tactile fremitus occurs with consolidation (e.g., pneumonia), whereas pleural effusion usually decreases fremitus due to fluid separating the lung tissue from the chest wall.
D. Hyperresonance is characteristic of conditions with excess air in the lungs, such as pneumothorax or emphysema, not pleural effusion.
Correct Answer is A
Explanation
Rationale:
A. Tachypnea (increased respiratory rate) is a common manifestation of pneumonia due to impaired gas exchange and hypoxia.
B. Hypothermia is not typical; pneumonia usually causes fever or low-grade hyperthermia.
C. Pulse deficit is related to arrhythmias and is not a characteristic finding of pneumonia.
D. Bradycardia is not typical; clients with pneumonia may experience tachycardia as a compensatory response to hypoxia and fever.
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