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 A
Explanation
Choice A reason:
In a state of shock, the body prioritizes blood flow to vital organs such as the myocardium (heart muscle) and the brain. This is because these organs are essential for survival, and their function is critical. The body's compensatory mechanisms ensure that blood is diverted to these areas to maintain their perfusion, even at the expense of less vital organs.
Choice B reason:
The pulmonary vasculature, which involves the blood vessels of the lungs, is important for gas exchange but is not specifically prioritized in the same way that the myocardium and brain are during shock. While maintaining adequate oxygenation is crucial, the body’s immediate focus is on sustaining the heart and brain.
Choice C reason:
The small and large bowel are not considered high-priority organs during shock. Blood flow to the gastrointestinal tract can be reduced to preserve perfusion to more vital organs. This reduced blood flow can result in decreased bowel activity and hypoactive bowel sounds.
Choice D reason:
While the hepatic (liver) and renal (kidneys) vasculature are important for detoxification and fluid balance, they are not prioritized over the heart and brain during shock. Reduced perfusion to these organs can lead to liver and kidney dysfunction, but the immediate priority is ensuring the survival of the heart and brain.
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