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
Explanation
Choice A rationale
Changing gloves between tasks on the same client is a key infection control practice. This prevents cross-contamination between different body sites and reduces the risk of spreading infection.
Choice B rationale
Washing hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile is not recommended. Clostridium difficile spores are not killed by alcohol-based hand rubs. Handwashing with soap and water is more effective.
Choice C rationale
Using alcohol-based hand rubs before administering eye drops for a client is a good practice, but it is not the most important information to reinforce. Hand hygiene is crucial in all aspects of patient care to prevent the spread of infection.
Choice D rationale
Keeping artificial nails trimmed short is a good practice, but it is not the most important information to reinforce. Artificial nails can harbor bacteria and other pathogens, increasing the risk of infection transmission.
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
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