A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?

Choice A: Collect patient information

This is the first step in the nursing process, known as the assessment phase. During this phase, the nurse gathers comprehensive information about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s health needs and planning appropriate care.

Choice B: Identify any clinical problems

The second step is the diagnosis phase, where the nurse analyzes the collected data to identify the patient’s health problems. These problems can be actual or potential issues that require nursing intervention. Accurate identification of clinical problems is crucial for developing an effective care plan.

Choice C: Decide a plan of action

The third step is the planning phase. In this phase, the nurse sets measurable and achievable goals for the patient’s care and decides on the appropriate nursing interventions to address the identified clinical problems. The plan of action should be individualized to meet the specific needs of the patient.

Choice D: Carry out the plan

The fourth step is the implementation phase, where the nurse executes the planned interventions. This may involve administering medications, providing education, performing procedures, or coordinating with other healthcare professionals. The goal is to achieve the desired patient outcomes as outlined in the care plan.

Choice E: Determine whether the plan was effective

The final step is the evaluation phase. In this phase, the nurse assesses the patient’s response to the implemented interventions and determines whether the goals of the care plan have been met. If the desired outcomes are not achieved, the nurse may need to revise the care plan and repeat the process.

Choice A: Alkalosis
Alkalosis occurs when the blood pH is higher than the normal range, specifically above 7.45. This condition indicates that the blood is too alkaline. Causes of alkalosis can include hyperventilation, loss of stomach acid through vomiting, or an overuse of diuretics. Since a blood pH of 7.21 is below the normal range, it does not indicate alkalosis.
Choice B: Normal Blood pH
The normal pH range for blood is between 7.35 and 7.45. This range is crucial for the body’s metabolic processes and enzyme functions. A blood pH of 7.21 is below this range, indicating an abnormal condition.
Choice C: Acidosis
Acidosis is the correct answer. It occurs when the blood pH drops below 7.35, indicating that the blood is too acidic. A pH of 7.21 is significantly below the normal range, confirming acidosis. This condition can result from various factors, including respiratory issues that lead to an accumulation of carbon dioxide or metabolic problems that increase acid production or decrease bicarbonate levels.
Choice D: Hyperkalemia
Hyperkalemia refers to an elevated level of potassium in the blood, not a change in blood pH. While hyperkalemia can be associated with acidosis, it is not defined by the pH level itself. Therefore, a blood pH of 7.21 does not directly indicate hyperkalemia.