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 ["A","B","D"]
Explanation
Choice A rationale
Daily measurement of abdominal girth is crucial in patients with an intestinal obstruction undergoing continuous gastrointestinal decompression. This is because any changes in the abdominal girth can indicate an improvement or worsening of the obstruction. Regular monitoring allows for timely intervention and adjustment of the care plan.
Choice B rationale
Maintaining the patient in Fowler’s position can help promote the drainage of gastric contents via the nasogastric tube. This position, where the patient is seated in bed at an angle of 45-60 degrees, uses gravity to assist in the drainage process, thereby potentially alleviating discomfort and reducing the risk of aspiration.
Choice C rationale
Moistening the patient’s lips with lemon glycerin swabs is not recommended. While it’s important to keep the patient’s lips moist to prevent dryness and cracking due to the nasogastric tube, lemon glycerin swabs can potentially dry out the lips more and cause irritation.
Choice D rationale
Using sterile water to irrigate the nasogastric tube is a standard practice in managing patients with a nasogastric tube. This helps ensure the patency of the tube and prevent blockages, allowing for effective gastrointestinal decompression.
Correct Answer is C
Explanation
The correct answer is Choice C.
Step 1 is to interpret the laboratory values. The glucose level is within the normal range (7099 mg/dL). The chloride level is within the normal range (97-107 mEq/L). The sodium level is within the normal range (135-145 mEq/L). However, the potassium level is low (normal range is 3.5-5.0 mEq/L)89101112.
Step 2 is to plan the action based on the interpretation. Given the low potassium level, the nurse should plan to request a potassium replacement
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