A nurse is providing care for a patient suffering from severe diarrhea. Which acid-base disorder is the patient at risk of developing?

Metabolic Alkalosis

Respiratory Alkalosis

Respiratory Acidosis

Metabolic Acidosis

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Metabolic alkalosis is a condition characterized by an increase in the pH of the blood due to an excess of bicarbonate (HCO3-) in the body. It is not typically caused by severe diarrhea. In fact, diarrhea can often lead to a loss of bicarbonate, which can contribute to metabolic acidosis.
Causes of metabolic alkalosis include: excessive vomiting, use of diuretics, and excessive intake of alkali such as antacids. Clinical manifestations of metabolic alkalosis include: muscle twitching, paresthesias, seizures, confusion, and lethargy.
Choice B rationale:
Respiratory alkalosis is a condition characterized by a decrease in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to an increase in blood pH. It is caused by hyperventilation, which removes excess CO2 from the body. Severe diarrhea does not typically cause hyperventilation.
Causes of respiratory alkalosis include: anxiety, hyperventilation syndrome, high altitude sickness, and pulmonary embolism. Clinical manifestations of respiratory alkalosis include: lightheadedness, dizziness, paresthesias, palpitations, and tetany.
Choice C rationale:
Respiratory acidosis is a condition characterized by an increase in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to a decrease in blood pH. It is caused by hypoventilation, which prevents the body from removing enough CO2. Severe diarrhea does not typically cause hypoventilation.
Causes of respiratory acidosis include: chronic obstructive pulmonary disease (COPD), pneumonia, asthma, and neuromuscular disorders.
Clinical manifestations of respiratory acidosis include: headache, confusion, somnolence, and coma.
Choice D rationale:
Metabolic acidosis is a condition characterized by a decrease in the pH of the blood due to an excess of acid in the body or a loss of bicarbonate. Severe diarrhea can lead to metabolic acidosis through several mechanisms:
Loss of bicarbonate in the stool: Diarrhea often contains a significant amount of bicarbonate, which can be lost from the body in large amounts during severe diarrheal episodes. This loss of bicarbonate can lead to a decrease in the blood's pH, resulting in metabolic acidosis.
Dehydration: Severe diarrhea can also lead to dehydration, which can concentrate acids in the blood and contribute to metabolic acidosis.
Lactic acidosis: In some cases, severe diarrhea can also cause lactic acidosis, a type of metabolic acidosis that occurs when there is a buildup of lactic acid in the body. This can happen due to impaired circulation or tissue hypoxia, which can occur as a complication of severe diarrhea.

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Correct Answer is D

Explanation

Rationale for Choice A:

Hydroxychloroquine does not typically cause hair loss as a significant side effect. While some anecdotal reports have suggested hair thinning as a possibility, it's not a well-established or common occurrence in clinical studies.

If a patient experiences hair loss while on hydroxychloroquine, it's essential to rule out other potential causes, such as underlying medical conditions, stress, or nutritional deficiencies.

It's also important to note that some individuals may have a personal predisposition to hair loss, and medications can sometimes trigger or exacerbate this issue.

Rationale for Choice B:

Hydroxychloroquine is not known to cause a burst of energy. In fact, some patients may experience fatigue or drowsiness as a side effect.

It's crucial to inform patients about potential side effects to manage expectations and promote adherence to treatment.

If a patient experiences unexpected energy changes while taking hydroxychloroquine, it's essential to report this to their healthcare provider for further evaluation.

Rationale for Choice C:

Hydroxychloroquine is generally recommended to be taken with food or milk to reduce potential gastrointestinal side effects such as nausea and vomiting.

Taking it on an empty stomach could increase the risk of these side effects, which could impact medication adherence and effectiveness.

Rationale for Choice D:

Retinal damage is the most serious adverse effect of hydroxychloroquine. It can lead to irreversible vision loss if not detected and managed early.

Patients taking hydroxychloroquine must undergo regular eye examinations to monitor for any signs of retinal toxicity.

Early detection and prompt discontinuation of the medication can often prevent permanent vision loss.

It's crucial for nurses to educate patients about this potential risk and emphasize the importance of regular eye exams.

A. Massage the site with scented oils B. Apply warm compresses to the site C. Administer topical lidocaine to the site D. Administer prescribed oral pain medication

Correct Answer is B

Explanation

Choice A rationale:
Massaging the site with scented oils is not recommended for pain relief after removal of a peripheral vascular access device. There is no evidence to support the effectiveness of scented oils in this context.
Additionally, some scented oils can be irritating to the skin, which could potentially worsen the pain, redness, and swelling.
It's crucial to use products that are specifically designed for wound care and pain management, and to follow the healthcare provider's instructions.
Choice B rationale:
Applying warm compresses to the site is an effective and recommended intervention to alleviate pain, redness, and swelling after removal of a peripheral vascular access device.
Warm compresses have the following beneficial effects:
Vasodilation: They promote blood flow to the area, which helps to reduce inflammation and pain. Muscle relaxation: The warmth helps to relax tense muscles, further easing discomfort.
Pain relief: Warmth can directly inhibit pain signals, providing a soothing sensation.
Increased circulation: Improved blood flow can help to remove inflammatory substances and promote healing. It's important to use a clean, warm compress and to apply it for 15-20 minutes at a time, several times a day.
Choice C rationale:
Topical lidocaine is a local anesthetic that can temporarily numb the skin.
While it can be used for pain relief, it's not typically the first-line intervention for pain associated with removal of a peripheral vascular access device.
Warm compresses are often preferred as they provide a more natural and non-invasive approach to pain management.
Choice D rationale:
Oral pain medication may be necessary if warm compresses do not provide adequate pain relief.
However, it's important to follow the healthcare provider's instructions regarding the type and dosage of pain medication to use.
Over-the-counter pain relievers, such as acetaminophen or ibuprofen, may be sufficient in some cases. Stronger prescription pain medication may be needed for more severe pain.

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A nurse is providing care for a patient suffering from severe diarrhea. Which acid-base disorder is the patient at risk of developing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The primary healthcare provider prescribes Hydroxychloroquine for a patient. What information should the nurse include when discussing this medication with the patient?

Correct Answer is D

Explanation

Rationale for Choice A:

Rationale for Choice B:

Rationale for Choice C:

Rationale for Choice D:

A nurse is attending to a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. What action should the nurse take to alleviate the pain after removing the device?

Correct Answer is B

Explanation

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