. A nurse is reviewing the medical record of a client who has metabolic acidosis. The nurse should realize that which of the following findings contributes to the development of metabolic acidosis?

Diarrhea

Salicylate intoxication

Hyperventilation

Vomiting

Answer and Explanation

The Correct Answer is A

Rationale:

A. Diarrhea causes loss of bicarbonate (HCO₃⁻) from the intestines, leading to metabolic acidosis. This is a common non-anion gap cause of metabolic acidosis.

B. While salicylate intoxication can initially cause respiratory alkalosis, it may later lead to mixed acid-base disturbances, including metabolic acidosis. However, it is not the most direct or common cause in this context.

C. Hyperventilation causes respiratory alkalosis, not metabolic acidosis, due to excessive loss of CO₂.

D. Vomiting leads to loss of gastric acid (HCl), which typically results in metabolic alkalosis, not acidosis

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Correct Answer is D

Explanation

Rationale:
A. An erythrocyte sedimentation rate (ESR) is used to detect inflammation but is not relevant in the immediate management of hyperkalemia.
B. Administering potassium would worsen the client's already elevated potassium level.
C. Restricting fluids is not an appropriate initial response for hyperkalemia and can increase the risk of complications.
D. A potassium level of 6.8 mEq/L is critically high and can cause life-threatening cardiac dysrhythmias. A 12-lead ECG is essential to assess for cardiac effects of hyperkalemia, such as peaked T waves or widened QRS complexes.

A. Introduce a regular diet B. Rehydrate. C. Maintain fluid therapy. D. Assess fluid balance.

Correct Answer is B

Explanation

Rationale:
A. Introducing a regular diet is important but not the immediate priority in severe diarrhea.
B. Rehydration is the most critical initial step to prevent or treat dehydration and shock.
C. Maintaining fluid therapy is important after rehydration is initiated but not the first action.
D. Assessing fluid balance is necessary but secondary to initiating rehydration.

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. A nurse is reviewing the medical record of a client who has metabolic acidosis. The nurse should realize that which of the following findings contributes to the development of metabolic acidosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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