A nurse is taking care of a patient who is nauseous and vomiting.
Which of the following acid-base imbalances should the nurse identify the patient is at risk for?
Respiratory alkalosis.
Metabolic alkalosis.
Metabolic Acidosis.
Respiratory acidosis.
Respiratory acidosis.
The Correct Answer is B
Choice A rationale
Respiratory alkalosis is typically associated with hyperventilation, which can occur in conditions such as anxiety, fever, or certain lung diseases. However, it is less likely in a patient who is nauseous and vomiting.
Choice B rationale
Metabolic alkalosis is a condition that can occur due to the loss of acid from the body, which can happen when a patient is vomiting. When a person vomits, they lose stomach acid (hydrochloric acid), and this can disrupt the acid-base balance in the body, leading to metabolic alkalosis.
Choice C rationale
Metabolic acidosis is typically associated with conditions that cause the accumulation of acid in the body or the loss of bicarbonate, such as kidney disease, lactic acidosis, or certain poisonings. It is less likely in a patient who is nauseous and vomiting.
Choice D rationale
Respiratory acidosis is typically associated with conditions that cause an inability to remove enough carbon dioxide from the body, such as chronic obstructive pulmonary disease (COPD) or airway obstruction. It is less likely in a patient who is nauseous and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypothermia is not a typical finding in a client who has had diarrhea for several days. Diarrhea does not typically affect the body’s ability to regulate temperature.
Choice B rationale
Dehydration is a common finding in a client who has had diarrhea for several days. Diarrhea can lead to significant fluid and electrolyte loss, causing dehydration.
Choice C rationale
Decreased bowel sounds are not typically associated with diarrhea. In fact, hyperactive bowel sounds are more common due to increased intestinal motility.
Choice D rationale
A rigid abdomen is not a typical finding in a client who has had diarrhea for several days. A rigid abdomen may indicate a serious condition such as peritonitis or bowel obstruction, which are not typically associated with diarrhea.
Correct Answer is B
Explanation
Choice A rationale
Pushing the syringe plunger to empty the formula faster is not recommended. This can lead to complications such as aspiration, diarrhea, or abdominal cramping. The formula should be allowed to flow slowly by gravity.
Choice B rationale
Holding the syringe high enough for the formula to empty gradually by gravity is the correct method for intermittent feeding. This allows for a slow, controlled flow of the formula, which can help prevent complications.
Choice C rationale
Positioning the patient in a supine position during feeding is not recommended. The patient should be in an upright position, at least 30 degrees, to reduce the risk of aspiration.
Choice D rationale
Flushing the tubing before feeding only is not correct. The tubing should be flushed before and after feedings to maintain patency and prevent clogging.
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