Vomiting of stomach contents or continuous nasogastric suctioning may predispose to the development of:
Metabolic acid deficit (metabolic alkalosis)
Carbonic acid excess (respiratory acidosis)
Metabolic acid excess (metabolic acidosis)
Carbonic acid deficit (respiratory alkalosis)
The Correct Answer is A
Choice A: Metabolic Acid Deficit (Metabolic Alkalosis)
Vomiting or continuous nasogastric suctioning leads to the loss of gastric contents, which are rich in hydrochloric acid (HCl)1. This loss results in a decrease in the body’s acid levels, leading to a condition known as metabolic alkalosis2. Metabolic alkalosis is characterized by an increase in blood pH due to the loss of hydrogen ions (H+) and an increase in bicarbonate (HCO3-) levels. This condition can cause symptoms such as muscle twitching, hand tremors, and light-headedness.
Choice B: Carbonic Acid Excess (Respiratory Acidosis)
Carbonic acid excess, or respiratory acidosis, occurs when there is an accumulation of carbon dioxide (CO2) in the blood, leading to a decrease in blood pH3. This condition is typically caused by respiratory issues such as hypoventilation, chronic obstructive pulmonary disease (COPD), or severe asthma. It is not directly related to vomiting or nasogastric suctioning, which primarily affect the metabolic component of acid-base balance.
Choice C: Metabolic Acid Excess (Metabolic Acidosis)
Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of metabolic acids or a loss of bicarbonate. Common causes include renal failure, diabetic ketoacidosis, and severe diarrhea. Vomiting or nasogastric suctioning, which result in the loss of gastric acid, do not lead to metabolic acidosis but rather to metabolic alkalosis.
Choice D: Carbonic Acid Deficit (Respiratory Alkalosis)
Respiratory alkalosis occurs when there is a decrease in carbon dioxide levels in the blood, leading to an increase in blood pH. This condition is often caused by hyperventilation due to anxiety, fever, or high altitude. It is not related to the loss of gastric contents through vomiting or nasogastric suctioning, which primarily affect the metabolic component of acid-base balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Discontinuing the drug at the first signs of toxicity might seem like a straightforward solution, but it is not always the best approach. Some drugs are essential for treating serious conditions, and stopping them abruptly can cause more harm than good. Instead, the nurse should monitor the patient closely and consult with the healthcare provider to adjust the dosage or switch to a safer alternative if necessary.
Choice B Reason:
Teaching the patient how to treat symptoms if they develop is important, but it is not sufficient on its own. While patient education is a crucial aspect of managing drug side effects, it should be part of a broader strategy that includes regular monitoring and medical supervision.
Choice C Reason:
Ensuring that complete blood counts are ordered periodically is a good practice, especially for drugs that can affect blood cells. However, this approach is too narrow. Toxic side effects can impact various organs and systems, so a comprehensive monitoring plan is necessary.
Choice D Reason:
This is the correct answer. Monitoring the function of all organs potentially affected by the drug is the most comprehensive and effective approach. This includes regular blood tests, liver function tests, kidney function tests, and other relevant assessments. By closely monitoring the patient’s organ functions, the healthcare team can detect early signs of toxicity and take appropriate action to prevent serious complications.
Correct Answer is C
Explanation
Choice A Reason:
The exhaustion stage is the final phase of the general adaptation syndrome (GAS). It occurs when the body has been exposed to stress for a prolonged period and can no longer maintain resistance. Symptoms of exhaustion include fatigue, burnout, depression, and decreased stress tolerance. Since the student is experiencing an immediate response to a sudden stressor, this stage does not apply.
Choice B Reason:
Adaptation is not a specific stage in the general adaptation syndrome. The correct stages are alarm, resistance, and exhaustion. Therefore, this choice is incorrect.
Choice C Reason:
This is the correct answer. The alarm stage is the initial phase of the general adaptation syndrome, also known as the “fight-or-flight” response. During this stage, the body reacts to a stressor by activating the sympathetic nervous system, which leads to increased heart rate, rapid breathing, and heightened alertness. The student’s reaction to the near-miss accident fits this description perfectly.
Choice D Reason:
The stage of resistance is the second phase of the general adaptation syndrome. During this stage, the body attempts to adapt to the stressor and return to a state of balance. If the stressor persists, the body remains on high alert, but the initial shock of the alarm stage has passed. Since the student’s response is immediate and acute, it aligns with the alarm stage rather than the resistance stage.
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