A nurse is caring for a client who has nausea and is vomiting. The nurse should identify that the client is at risk for which of the following acid-base imbalances?
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
Respiratory alkalosis
The Correct Answer is A
Choice A reason: Metabolic alkalosis is a condition in which the blood pH is elevated due to an excess of bicarbonate or a loss of acid. It can be caused by nausea and vomiting, as they result in the loss of gastric acid and the retention of bicarbonate.
Choice B reason: Respiratory acidosis is a condition in which the blood pH is lowered due to an accumulation of carbon dioxide. It can be caused by hypoventilation, airway obstruction, or lung diseases. It is not related to nausea and vomiting.
Choice C reason: Metabolic acidosis is a condition in which the blood pH is lowered due to an excess of acid or a loss of bicarbonate. It can be caused by diabetic ketoacidosis, renal failure, or lactic acidosis. It is not caused by nausea and vomiting.
Choice D reason: Respiratory alkalosis is a condition in which the blood pH is elevated due to a loss
carbon dioxide. It can be caused by hyperventilation, anxiety, fever, or aspirin overdose. It is not common in clients who have nausea and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
Correct Answer is A
Explanation
Choice A reason: Donning sterile gloves is an essential step to prevent contamination and infection during the insertion of an indwelling urinary catheter. The nurse should also use aseptic technique and a sterile catheter kit.
Choice B reason: Applying an oil-based lubricant to the indwelling urinary catheter is not recommended, as it can damage the latex material and increase the risk of catheter-associated urinary tract infection (CAUTI). The nurse should use a water-soluble lubricant instead.
Choice C reason: Testing the balloon on the indwelling urinary catheter before insertion is a good practice, as it ensures that the balloon is functioning properly and does not leak or burst. The nurse should inflate and deflate the balloon with sterile water or saline using a syringe.
Choice D reason: Using one cotton swab to clean the client's urinary meatus is not sufficient, as it may not remove all the bacteria and debris. The nurse should use at least three cotton swabs and clean the meatus from front to back in a circular motion. The nurse should also use an antiseptic solution such as chlorhexidine or povidone-iodine.
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