A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
Metabolic alkalosis
The Correct Answer is B
Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.
Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.
Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.
Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Use good body mechanics is correct. Good body mechanics involve using the body in an efficient and careful way to prevent injury. This includes bending at the knees instead of the waist, keeping the back straight, and using the legs to lift heavy objects. Proper body mechanics reduce the strain on the back and joints, preventing injuries.
Choice B Reason:
Maintain proper posture is also important but is part of using good body mechanics. Proper posture involves keeping the spine in a neutral position, avoiding slouching, and ensuring that the head is aligned with the spine. This helps distribute weight evenly and reduces the risk of injury.
Choice C Reason:
Use assistive devices is correct. Assistive devices such as transfer boards, mechanical lifts, and gait belts can help reduce the physical strain on nurses when moving or lifting patients. These devices are designed to make tasks safer and easier, thereby minimizing the risk of back and joint injuries.
Choice D Reason:
Stay physically fit is also important. Physical fitness helps maintain muscle strength, flexibility, and endurance, which are crucial for performing physically demanding tasks. Regular exercise can help prevent injuries by improving overall body mechanics and reducing fatigue.
Correct Answer is C
Explanation
Advance directives are legal documents that allow individuals to outline their preferences for medical treatment in case they become unable to communicate their decisions. These documents typically include a living will and a durable power of attorney for healthcare. The living will specifies the types of medical treatment a person wishes to receive or avoid, while the durable power of attorney for healthcare designates a trusted individual to make healthcare decisions on their behalf.
Choice A Reason:
“I will get my regular doctor to approve my plan before I hand it in to the hospital.”
This statement indicates a misunderstanding of the purpose of advance directives. While it is important to discuss your advance directives with your healthcare provider, the primary purpose of these documents is to communicate your wishes regarding medical treatment, not to seek approval from your doctor. The advance directive is a personal document that reflects your values and preferences for medical care.
Choice B Reason:
“I know they won’t go ahead with the surgery unless I prepare these forms.”
This statement also reflects a misunderstanding. While having advance directives in place is highly recommended, it is not typically a prerequisite for undergoing surgery. Advance directives are important for ensuring that your medical wishes are respected, but they are not mandatory for surgical procedures. The focus should be on making sure your wishes are known and documented, rather than on the necessity of the forms for surgery.
Choice C Reason:
“I plan to write that I do not want them to keep me on a breathing machine.”
This statement correctly reflects the purpose of an advance directive. It shows that the patient understands that they can specify their preferences for medical treatment, such as whether or not they want to be kept on a breathing machine. This type of instruction is a common component of a living will, which is part of an advance directive. It ensures that healthcare providers are aware of the patient’s wishes regarding life-sustaining treatments.
Choice D Reason:
“I would rather have my brother make decisions for me, but I know he has to be my wife.”
This statement is incorrect and confusing. It seems to mix up the roles of different individuals. In an advance directive, you can designate a healthcare proxy or durable power of attorney for healthcare, who can be any trusted person, not necessarily a spouse. The statement also contains a factual error, as it implies that the brother must be the patient’s wife, which is not possible. The correct understanding is that you can choose any trusted individual to make healthcare decisions on your behalf.
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