A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid- base imbalances?

Metabolic acidosis

Respiratory alkalosis

Metabolic alkalosis

Respiratory acidosis

Answer and Explanation

The Correct Answer is C

C. Metabolic alkalosis is characterized by an increase in serum bicarbonate levels, resulting in an imbalance in the body's acid-base equilibrium towards alkalinity. Excessive ingestion of antacids, particularly those containing bicarbonate or calcium carbonate, can lead to an excessive accumulation of bicarbonate ions in the body, causing metabolic alkalosis.
A. Excessive ingestion of antacids would not typically cause metabolic acidosis because antacids containing bicarbonate or calcium carbonate actually increase bicarbonate levels, leading to alkalosis rather than acidosis.
B. Respiratory alkalosis occurs due to hyperventilation, leading to a decrease in carbon dioxide levels and subsequent alkalosis. Excessive ingestion of antacids is not typically associated with respiratory alkalosis.

D. Respiratory acidosis occurs due to hypoventilation, leading to an increase in carbon dioxide levels and subsequent acidosis. Excessive ingestion of antacids is not typically associated with respiratory acidosis.

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Correct Answer is C

Explanation

C. Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
A. The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
D. While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.

A. Discard the radioactive device in the client's trash can. B. Keep soiled bed linens in the client's room. C. Instruct visitors to remain 3 feet from the client. D. Limit time for visitors to 2 hr per day.

Correct Answer is D

Explanation

D. Limiting the time that visitors spend with the client is a reasonable precaution to reduce their overall radiation exposure. Prolonged exposure to radiation can increase the risk of adverse effects. By limiting visitors to a specific time frame, the nurse can help control their exposure while still allowing for social support and companionship.
A. Discarding radioactive materials in regular trash cans can pose significant risks to sanitation workers, the environment, and public health.
B. Proper disposal of soiled linens contaminated with radioactive materials is essential to prevent radiation exposure to others. Soiled linens should be handled and disposed of according to institutional protocols for managing radioactive waste.
C. Maintaining a safe distance from the client is an important radiation safety precaution. However, this alone may not be sufficient to ensure adequate protection, depending on the specific circumstances of the treatment and the level of radiation emitted by the sources.

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A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid- base imbalances?

Nursing Test Bank

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