An emergency department nurse admits a client who has tried to commit suicide by taking an overdose of hydromorphone (Dilaudid), a narcotic. For which acid-base imbalance should the nurse assess this client for?
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
The Correct Answer is D
Rationale:
A. Respiratory alkalosis results from hyperventilation, which is unlikely with opioid overdose.
B. Metabolic acidosis can occur from other causes but is not the primary imbalance here.
C. Metabolic alkalosis is not associated with opioid overdose.
D. Respiratory acidosis occurs due to hypoventilation caused by opioid-induced respiratory depression, leading to CO₂ retention and decreased pH.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Rationale:
A. Dysrhythmias may occur due to increased CO₂ levels and acid-base imbalance affecting cardiac conduction.
B. Barrel chest is a common physical finding in clients with chronic COPD due to air trapping and lung hyperinflation.
C. Difficulty arousing the client may indicate CO₂ narcosis, a sign of worsening respiratory acidosis.
D. Confusion and disorientation, such as repeatedly asking "Where am I?", are neurological signs of elevated CO₂ levels.
E. Deep, rapid respirations (Kussmaul respirations) are typical of metabolic acidosis, not respiratory acidosis from COPD.
Correct Answer is C
Explanation
Rationale:
A. Counting wet diapers provides general insight into fluid output, but it is not the most accurate measure of overall fluid status.
B. Measuring head circumference is useful for assessing neurological changes or growth, not hydration.
C. Daily weight is the most accurate and sensitive indicator of fluid balance in infants, especially when performed consistently.
D. Vital signs can reflect dehydration, but they are less reliable than daily weight for ongoing monitoring of rehydration progress.
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