A nurse is caring for a client in the emergency department (ED) who has high anxiety and shallow respirations at a rate of 30/min. Which of the following acid-base disturbances is the client most likely experiencing?

Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

A. Respiratory acidosis occurs due to hypoventilation, resulting in carbon dioxide retention. This condition is characterized by slow, shallow breathing and confusion, which is not consistent with the client's rapid respiratory rate of 30/min.
B. Respiratory alkalosis is typically caused by hyperventilation, where excessive breathing leads to a decrease in carbon dioxide levels. The client's symptoms of high anxiety and rapid, shallow respirations are indicative of hyperventilation, making respiratory alkalosis the most likely diagnosis.
C. Metabolic acidosis is characterized by deep, rapid breathing (Kussmaul respirations) as the body attempts to expel excess acid. The client's shallow respirations are inconsistent with the breathing pattern seen in metabolic acidosis.
D. Metabolic alkalosis usually presents with symptoms such as dizziness and tingling, often with compensatory slow respirations. The rapid respiratory rate in this case does not suggest metabolic alkalosis, making this option unlikely.

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Correct Answer is D

Explanation

A. Hyperventilation: Hyperventilation is more commonly associated with respiratory alkalosis or anxiety rather than hypokalemia. Hypokalemia does not typically cause hyperventilation.

B. Bradypnea: Bradypnea (slow breathing) is not a common finding in hypokalemia. Hypokalemia can affect muscle function, including respiratory muscles, but bradypnea is not a characteristic sign.

C. Syncope: While syncope (fainting) can occur due to various conditions, it is not a specific or common finding directly associated with hypokalemia. Hypokalemia mainly affects the heart and muscles.

D. U waves on electrocardiogram: U waves are a classic electrocardiogram (ECG) finding associated with hypokalemia. These waves appear after the T wave and are indicative of the electrolyte imbalance affecting cardiac repolarization.

A. The client has developed confusion. B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L). C. The client has a positive Chvostek's sign. D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL).

Correct Answer is A

Explanation

A. The client has developed confusion: Hypotonic fluids can cause a rapid shift of water into cells, potentially leading to cerebral edema. This can manifest as confusion or altered mental status, which is a serious adverse effect requiring immediate attention.

B. The client's serum sodium is 140 mEq/L (135 to 145 mEq/L): A serum sodium level within the normal range indicates that the hypotonic fluid therapy is likely effective in correcting hypernatremia, and does not suggest an adverse effect.

C. The client has a positive Chvostek's sign: A positive Chvostek's sign is indicative of hypocalcemia rather than an adverse effect of hypotonic fluid administration. This sign is related to low calcium levels and is not a direct result of hypotonic fluid therapy.

D. The client's blood urea nitrogen (BUN) level is 18 mg/dL (10 to 20 mg/dL): This BUN level is within normal limits and does not suggest an adverse effect of hypotonic fluid therapy. BUN levels can be affected by various factors, but this value alone is not indicative of an adverse reaction.

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A nurse is caring for a client in the emergency department (ED) who has high anxiety and shallow respirations at a rate of 30/min. Which of the following acid-base disturbances is the client most likely experiencing?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is A

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