A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?
Respiratory alkalosis
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis
The Correct Answer is C
Choice A reason: Respiratory alkalosis is typically associated with hyperventilation, which is not common in acute pulmonary edema.
Choice B reason: Metabolic acidosis can occur in pulmonary edema due to tissue hypoxia and lactic acid production, but respiratory acidosis is more directly related to the primary problem of gas exchange.
Choice C reason: Respiratory acidosis is likely in acute pulmonary edema due to impaired gas exchange and CO2 retention.
Choice D reason: Metabolic alkalosis is not typically associated with acute pulmonary edema and is less likely than respiratory acidosis in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While rest may help alleviate nausea, it is not the first action a nurse should take when a client on digoxin reports nausea, as it could be a sign of toxicity.
Choice B reason: A dietary consult may be beneficial in the long term but is not the immediate priority when a client reports nausea, which could be a symptom of digoxin toxicity.
Choice C reason: Requesting an order for an antiemetic is not the first step without assessing whether the nausea is due to digoxin toxicity, which can be life-threatening.
Choice D reason: Checking the client's vital signs is the correct first action because nausea can be a sign of digoxin toxicity, and vital signs may reveal other symptoms of toxicity.
Correct Answer is A
Explanation
Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.
Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.
Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.
Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.
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