A nurse is caring for a patient who is experiencing nausea and vomiting.
The nurse should identify that the patient 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 rationale:
Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid. When a person vomits, they lose hydrochloric acid, and the loss of this acid can cause the blood to become more basic. This shift in pH can lead to metabolic alkalosis, a condition characterized by high levels of bicarbonate in the blood, which makes it more alkaline (or less acidic). Symptoms of metabolic alkalosis can include muscle twitching, hand tremor, nausea or vomiting, and tingling in the face, hands or feet. In severe cases, it can cause prolonged muscle contractions or seizures.
Choice B rationale:
Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2) from the body, which causes the body’s fluids, especially the blood, to become too acidic. This can occur due to conditions that affect the lungs such as chronic obstructive pulmonary disease (COPD), asthma, or sleep apnea. However, in the case of a patient experiencing nausea and vomiting, respiratory acidosis is less likely to be the primary concern.
Choice C rationale:
Metabolic acidosis occurs when the body produces too much acid, or when the kidneys aren’t removing enough acid from the body. This can be caused by conditions such as kidney disease, lactic acidosis, or ketoacidosis. In the case of a patient experiencing nausea and vomiting, the primary concern would not typically be metabolic acidosis, as vomiting leads to a loss of stomach acid, which would more likely result in a state of alkalosis, not acidosis.
Choice D rationale:
Respiratory alkalosis is a condition that occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to rise and become too alkaline. When the blood is too alkaline, it means that it is not carrying enough carbon dioxide. This condition can be caused by fever, hyperventilation, or lack of oxygen. In the case of a patient experiencing nausea and vomiting, respiratory alkalosis is not typically the primary concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin to a client who is hyperventilating due to respiratory alkalosis would not be the appropriate action. Insulin is used to lower blood glucose levels in clients with hyperglycemia, such as those with diabetes mellitus. It does not directly address the issues of hyperventilation or respiratory alkalosis.
Choice B rationale:
Having the client breathe into a paper bag is the correct action in this case. When a person hyperventilates, they exhale more carbon dioxide (CO2) than they produce. This can lead to a state of respiratory alkalosis, where the blood becomes too alkaline due to the low levels of CO2. By breathing into a paper bag, the client re-inhales some of the exhaled CO2, helping to restore the balance of gases in the blood and alleviate the symptoms of respiratory alkalosis.
Choice C rationale:
Administering sodium bicarbonate to a client who is hyperventilating and has respiratory alkalosis would not be the appropriate action. Sodium bicarbonate is an alkalinizing agent used to treat conditions where there is too much acid in the body, such as metabolic acidosis. In this case, the client’s body is too alkaline due to the respiratory alkalosis, so administering an alkalinizing agent would exacerbate the condition.
Choice D rationale:
Having the client place their head between their knees would not be the appropriate action for a client who is hyperventilating due to respiratory alkalosis. This position is often used to help alleviate symptoms of dizziness or fainting, but it does not address the underlying issue of the imbalance of gases in the blood due to hyperventilation.
Correct Answer is ["A","C"]
Explanation
The correct answers are Choices A and C.
Choice A rationale: Ignoring the urge to defecate can lead to constipation because the longer stool remains in the colon, the more water is absorbed from it, making it harder and more difficult to pass. This can lead to a cycle of further constipation and discomfort.
Choice B rationale: Increased fiber in the diet usually helps prevent constipation by adding bulk to the stool and making it easier to pass. Therefore, it is not a cause of constipation, but rather a preventive measure.
Choice C rationale: Excessive laxative use can lead to dependence on laxatives for bowel movements and can disrupt normal bowel function. Over time, this can lead to constipation as the bowel becomes less responsive to normal stimuli.
Choice D rationale: Increased activity generally helps to prevent constipation by stimulating bowel motility. Physical exercise can enhance the efficiency of the digestive system, so it is not a cause of constipation.
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