A nurse is collecting data from a patient who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?
Hyperventilation
Cold, clammy skin
Increased blood pressure
Bradycardia
The Correct Answer is A
Choice A reason: Hyperventilation is a compensatory mechanism in metabolic acidosis where the body tries to decrease carbon dioxide levels to balance the acidity.
Choice B reason: Cold, clammy skin is not a typical manifestation of metabolic acidosis; it may be associated with shock or hypoglycemia.
Choice C reason: Increased blood pressure is not directly related to metabolic acidosis. It can be influenced by various factors, including stress or other underlying conditions.
Choice D reason: Bradycardia, or a slow heart rate, is not a common manifestation of metabolic acidosis. Tachycardia, or a fast heart rate, might be observed instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Diarrhea can lead to metabolic acidosis due to the loss of bicarbonate, which is a base, leading to a relative increase in acidity.
Choice B reason: Salicylate intoxication can initially cause respiratory alkalosis due to hyperventilation, but may later lead to metabolic acidosis as the body compensates.
Choice C reason: Vomiting typically leads to a loss of gastric acid, which would cause metabolic alkalosis, not acidosis.
Choice D reason: Hyperventilation is more commonly associated with respiratory alkalosis due to the excessive loss of CO2, which is an acid, not metabolic acidosis.
Correct Answer is A
Explanation
Choice A reason: Elevating the patient in a high Fowler's position can help improve lung expansion and oxygenation, and using an incentive spirometer along with coughing can help prevent atelectasis and pneumonia, which are common postoperative complications.
Choice B reason: Increasing oxygen to 70% without a specific indication could lead to oxygen toxicity, especially without assessing the patient's current oxygenation status.
Choice C reason: Switching to a rebreather mask is not indicated based on the given ABG results and could lead to CO2 retention.
Choice D reason: Positioning the patient prone and performing postural drainage are not typically first-line interventions for a patient one day post-thoracotomy and could be contraindicated due to the recent surgery.
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