The nurse caring for a client in the early stages of hypovolemic shock who is hyperventilating. The nurse monitors for which acid-base imbalance based on this clinical presentation?
Respiratory acidosis.
Respiratory alkalosis.
Metabolic acidosis.
Metabolic alkalosis.
The Correct Answer is B
Choice A reason: Respiratory acidosis. Respiratory acidosis occurs when there is inadequate ventilation, leading to increased carbon dioxide levels in the blood. Hyperventilation would not cause respiratory acidosis.
Choice B reason: Respiratory alkalosis. Hyperventilation results in excessive expulsion of carbon dioxide, leading to a decrease in carbonic acid levels in the blood. This causes respiratory alkalosis, which is expected in the early stages of hypovolemic shock as the body attempts to compensate for decreased oxygen delivery.
Choice C reason: Metabolic acidosis. Metabolic acidosis results from an accumulation of acid or loss of bicarbonate in the body. It is typically seen in the later stages of shock when lactic acid builds up due to anaerobic metabolism.
Choice D reason: Metabolic alkalosis. Metabolic alkalosis occurs due to an excessive loss of acids (e.g., through vomiting) or an accumulation of bicarbonate. Hyperventilation does not cause metabolic alkalosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Epinephrine. Epinephrine is the first-line treatment for anaphylactic shock. It rapidly reverses severe allergic reactions by reducing swelling, increasing blood pressure, and improving breathing.
Choice B reason: Rapid infusion of normal saline. While fluid resuscitation is important in managing anaphylactic shock, it is not the initial therapy of choice. Epinephrine should be administered first to counteract the allergic reaction.
Choice C reason: Dobutamine. Dobutamine is used to support cardiac function in certain types of shock but is not the first-line treatment for anaphylactic shock.
Choice D reason: Norepinephrine. Norepinephrine is a vasopressor used to treat severe hypotension and shock but is not the initial treatment for anaphylactic shock. Epinephrine is preferred to address the allergic reaction.
Correct Answer is C
Explanation
Choice A reason:
Elevating the head of the bed is a common practice in patient care but is not directly related to preventing hypovolemic shock. This action can help with respiratory comfort and drainage but does not address fluid balance or blood volume, which are critical in preventing hypovolemic shock.
Choice B reason:
Providing immediate pain relief is important for patient comfort and recovery but does not directly prevent hypovolemic shock. While controlling pain can reduce stress on the body, it does not address the fluid and blood volume concerns central to preventing hypovolemic shock.
Choice C reason:
Monitoring intake and output is crucial in preventing hypovolemic shock, especially in postoperative patients. This helps to ensure that fluid balance is maintained, and any significant losses (e.g., through bleeding, vomiting, or excessive drainage) are promptly addressed. Accurate monitoring allows for early intervention to prevent hypovolemic shock.
Choice D reason:
Practicing careful and consistent hand hygiene is essential for preventing infections, which can lead to septic shock, but it is not directly related to preventing hypovolemic shock. While important, hand hygiene does not specifically address the fluid and blood volume issues involved in hypovolemic shock.
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