Which intervention would the nurse include in the plan of care for a client with COPD and respiratory acidosis?

Assess level of consciousness

Monitor serum sodium

Check skin turgor

Administer diuretics

Answer and Explanation

The Correct Answer is A

a. Assess level of consciousness: Respiratory acidosis in COPD patients can lead to hypercapnia (elevated carbon dioxide levels), which may result in altered mental status, confusion, or decreased level of consciousness due to respiratory depression. Assessing the level of consciousness is important to monitor for signs of worsening respiratory distress or impending respiratory failure.

b. Monitor serum sodium: COPD patients with respiratory acidosis may retain carbon dioxide, leading to respiratory compensation by the kidneys through increased retention of bicarbonate ions. This retention of bicarbonate can result in metabolic alkalosis and potentially affect electrolyte balance, including sodium levels. Monitoring serum sodium levels is essential to detect any electrolyte imbalances that may occur as a result of respiratory acidosis and its compensatory mechanisms.

c. Check skin turgor: While checking skin turgor is a valuable assessment for hydration status, it may not be directly related to respiratory acidosis in COPD. However, it's still important to assess hydration status in COPD patients, especially those with exacerbations, as dehydration can exacerbate respiratory symptoms.

d. Administer diuretics: Diuretics are not typically indicated in the management of respiratory acidosis in COPD. In fact, diuretics can worsen respiratory acidosis by potentially causing volume depletion and further reducing effective gas exchange in already compromised lungs. Diuretics may be used cautiously in COPD patients with concomitant heart failure or volume overload, but their use should be carefully monitored and individualized.

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Correct Answer is A

Explanation

Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It's essential to address this condition promptly.

a. Assess for decreased respiratory rate: Metabolic alkalosis leads to hypoventilation as the body compensates by retaining carbon dioxide. Monitoring respiratory rate is crucial to detect any signs of respiratory distress or inadequate ventilation¹.

- Priority: High

b. Diet teaching to include low protein foods: While dietary adjustments are important, addressing the underlying cause (such as vomiting, diuretic use, or excessive alkali intake) is more critical. Low protein foods alone won't correct metabolic alkalosis.

- Priority: Low

c. Obtain daily weight: Daily weight monitoring is essential for assessing fluid balance, but it doesn't directly address metabolic alkalosis. Other interventions take precedence.

- Priority: Medium.

d. Check blood glucose: Blood glucose levels are not directly related to metabolic alkalosis. Focusing on acid-base balance and electrolyte levels is more relevant.

- Priority: Low

A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis

Correct Answer is A

Explanation

a. Metabolic alkalosis: Metabolic alkalosis can occur due to loss of gastric acid through suctioning of gastric contents via the nasogastric tube. Continuous suctioning of gastric contents can lead to loss of hydrogen ions (H+) and chloride ions (Cl-) from the stomach, resulting in metabolic alkalosis.

b. Metabolic acidosis: Metabolic acidosis is less likely in this scenario unless there are other factors contributing to acidosis, such as renal dysfunction or excessive administration of certain medications. Suctioning of gastric contents would lead to loss of acid, which could potentially predispose the client to metabolic alkalosis rather than metabolic acidosis.

c. Respiratory alkalosis: Respiratory alkalosis is less likely to occur in this scenario. Although the client is NPO and may be experiencing some respiratory compensation due to metabolic alkalosis, the primary acid-base disturbance would be metabolic rather than respiratory.

d. Respiratory acidosis: Respiratory acidosis is not typically associated with suctioning of gastric contents. Instead, it occurs due to inadequate alveolar ventilation, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. This imbalance is more commonly seen in conditions such as respiratory depression, neuromuscular disorders, or airway obstruction.

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Which intervention would the nurse include in the plan of care for a client with COPD and respiratory acidosis?

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