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. 0.9% sodium chloride (0.9% NaCl): This solution, also known as normal saline, is isotonic and contains the same concentration of sodium as extracellular fluid. It is the most appropriate choice for initial fluid resuscitation in hypovolemia due to severe bleeding because it rapidly expands intravascular volume, replaces sodium losses, and helps restore circulating blood volume.
A. This solution contains dextrose (glucose) and a small amount of sodium chloride. It provides some glucose for energy but has a lower sodium concentration compared to isotonic solutions like normal saline. While it may be used in certain situations, such as to provide maintenance fluids or correct mild dehydration, it is not the first choice for fluid resuscitation in hypovolemia due to severe bleeding because it does not adequately replace lost volume.
B. 3% sodium chloride (3% NaCl): This solution is hypertonic and has a high sodium concentration. It is not typically used for initial fluid resuscitation in hypovolemia due to severe bleeding. Hypertonic saline solutions like 3% NaCl are more commonly used in specific situations such as severe hyponatremia or cerebral edema.
C. 5% dextrose in water (D5W): This solution contains only dextrose and water and is isotonic until the dextrose is metabolized, after which it becomes hypotonic. D5W is not suitable for fluid resuscitation in hypovolemia due to severe bleeding because it does not provide adequate sodium or volume replacement.
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