The nurse identifies which client to be at risk for developing metabolic alkalosis? The client who:
has been vomiting for three days.
has had diarrhea for the past 24 hours.
has overdosed on heroin.
is admitted with an asthma exacerbation.
The Correct Answer is A
A. Vomiting results in loss of hydrochloric acid (HCl) from the stomach, leading to a loss of chloride ions (Cl-) and hydrogen ions (H+) from the body. This loss of hydrogen ions can result in an accumulation of bicarbonate ions (HCO3-) relative to hydrogen ions, leading to metabolic alkalosis. Therefore, this client is at risk for developing metabolic alkalosis due to prolonged vomiting.
B. Client who has had diarrhea for the past 24 hours: Diarrhea leads to loss of bicarbonate ions (HCO3-) from the body along with fluid and electrolytes. However, metabolic alkalosis is less likely to occur with diarrhea alone because the loss of bicarbonate ions is usually balanced by the loss of chloride ions (Cl-) and hydrogen ions (H+). Therefore, while diarrhea can lead to metabolic acidosis in some cases, it is less likely to cause metabolic alkalosis.
C. Client who has overdosed on heroin: Heroin overdose is not directly associated with metabolic alkalosis. In the context of heroin overdose, respiratory depression leading to respiratory acidosis is a more immediate concern. Therefore, this client is not at risk for developing metabolic alkalosis due to heroin overdose.
D. Client who is admitted with an asthma exacerbation: Asthma exacerbation can lead to respiratory alkalosis due to hyperventilation and excessive elimination of carbon dioxide (CO2) from the body. However, metabolic alkalosis is not a typical consequence of asthma exacerbation alone. Therefore, while this client may experience respiratory alkalosis, they are not at risk for developing metabolic alkalosis solely due to asthma exacerbation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Prioritizing essential information and presenting it first can increase the likelihood that the client grasps key concepts and retains important details. By focusing on the most crucial information initially, the client is more likely to understand and remember the core concepts of the teaching session. This approach helps prevent information overload and ensures that the client receives the most critical information upfront, enhancing their learning outcomes.
A. Extreme temperatures, whether too hot or too cold, can be distracting and uncomfortable for the client, potentially detracting from their ability to focus on the teaching session and retain information.
B. Postponing a teaching session if the client appears to be mildly anxious: This strategy acknowledges the importance of addressing the client's emotional state in facilitating effective learning. If a client appears to be mildly anxious or emotionally distressed, it may be beneficial to postpone the teaching session temporarily until the client feels more calm and receptive to learning. Addressing the client's emotional needs and ensuring a supportive environment can enhance their ability to engage in the teaching process and retain information effectively.
D. While some individuals may find listening to music relaxing or enjoyable, it can also serve as a distraction during a teaching session, especially if the music competes with the nurse's instructions or interferes with the client's ability to concentrate.
Correct Answer is D
Explanation
D. The sigmoid colon is the last part of the large intestine before the rectum. It functions to store fecal material and absorb water and electrolytes. Fecal material passing through the sigmoid colon tends to become more solid as water is absorbed, resulting in a more formed stool compared to other parts of the colon.
A. The transverse colon is located in the upper abdomen and is responsible for further absorption of water and electrolytes from the stool. Fecal material passing through the transverse colon tends to become more solid as water is absorbed, but it may not be as solid as stool from the descending colon or sigmoid colon.
B. The ascending colon is where stool is in a more liquid form as it moves up from the cecum. It undergoes further absorption of water and electrolytes as it travels through the colon, but it typically does not produce solid fecal output.
C. The ileum is the final portion of the small intestine and connects to the large intestine (colon). Stool passing through the ileum is still in a relatively liquid state as it contains undigested food particles, bile salts, and digestive enzymes. The primary function of the ileum is absorption of nutrients rather than water reabsorption, so fecal output from an ileostomy is usually more liquid.
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