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NurseDive Free Nursing Practice Question
A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-base imbalances should the nurse identify the client as being at risk for developing initially?
A. Metabolic acidosis
Metabolic acidosis occurs due to either increased production of metabolic acids, such as lactic acid in anaerobic metabolism, or decreased excretion of acids, such as in renal failure.Shallow respirations would not directly cause metabolic acidosis. While they may decrease the elimination of CO2, resulting in respiratory acidosis, they do not directly affect metabolic acid-base balance.
B. Respiratory alkalosis
Respiratory alkalosis occurs when there is excessive elimination of CO2 from the body, leading to decreased levels of carbonic acid (H2CO3) in the blood. Shallow respirations would not typically lead to excessive elimination of CO2; instead, they would likely result in CO2 retention, leading to respiratory acidosis rather than respiratory alkalosis.
C. Metabolic alkalosis
Metabolic alkalosis occurs due to excessive loss of acids or increased levels of bicarbonate (HCO3-) in the blood, often caused by conditions such as vomiting, excessive diuretic use, or excessive bicarbonate intake.Shallow respirations would not directly cause metabolic alkalosis. Again, while they may decrease CO2 elimination and lead to respiratory acidosis, they do not directly affect metabolic acid-base balance.
D. Respiratory acidosis
Respiratory acidosis is a condition that occurs when there is an excess of carbon dioxide (CO2) in the body due to inadequate ventilation. Shallow respirations can lead to inadequate elimination of CO2, resulting in its accumulation in the bloodstream. This can lead to an increase in carbonic acid (H2CO3) levels and a decrease in blood pH, causing respiratory acidosis.
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Full Explanation
Correct answer: D
A. Metabolic acidosis occurs due to either increased production of metabolic acids, such as lactic acid in anaerobic metabolism, or decreased excretion of acids, such as in renal failure.Shallow respirations would not directly cause metabolic acidosis. While they may decrease the elimination of CO2, resulting in respiratory acidosis, they do not directly affect metabolic acid-base balance.
B. Respiratory alkalosis occurs when there is excessive elimination of CO2 from the body, leading to decreased levels of carbonic acid (H2CO3) in the blood. Shallow respirations would not typically lead to excessive elimination of CO2; instead, they would likely result in CO2 retention, leading to respiratory acidosis rather than respiratory alkalosis.
C. Metabolic alkalosis occurs due to excessive loss of acids or increased levels of bicarbonate (HCO3-) in the blood, often caused by conditions such as vomiting, excessive diuretic use, or excessive bicarbonate intake.Shallow respirations would not directly cause metabolic alkalosis. Again, while they may decrease CO2 elimination and lead to respiratory acidosis, they do not directly affect metabolic acid-base balance.
D.Respiratory acidosis occurs when the lungs cannot remove enough of the carbon dioxide (CO2) produced by the body. Shallow respirations lead to inadequate elimination of CO2, causing it to accumulate in the bloodstream. This accumulation of CO2 results in an increase in carbonic acid (H2CO3) in the blood, leading to a decrease in blood pH and resulting in respiratory acidosis.
Therefore, the nurse should identify the client as being at risk for developing respiratory acidosis initially due to the shallow respirations of 9/min.
Similar Questions
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
A. Generalized urticaria.
Allergic reactions can occur during a blood transfusion, and one of the common signs is the development of hives or a generalized skin rash. Urticaria is characterized by raised, itchy, and reddened skin patches that may appear and disappear over time. The other findings listed are not specific to an allergic transfusion reaction: Distended jugular veins: Distended jugular veins may indicate an increase in central venous pressure, which can occur in conditions like heart failure or fluid overload. It is not directly associated with an allergic transfusion reaction. Blood pressure 184/92 mm Hg: A high blood pressure reading can be an indication of hypertension or an acute hypertensive crisis. It is not typically related to an allergic transfusion reaction. Bilateral flank pain: Bilateral flank pain can have various causes, such as kidney stones, urinary tract infections, or musculoskeletal issues. It is not a specific finding related to an allergic transfusion reaction.
B. Distended jugular veins.
C. Blood pressure 184/92 mm Hg.
D. Bilateral flank pain.
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?
A. Nausea and vomiting
Severe hyponatremia can cause nausea and vomiting due to the disturbance in electrolyte balance and the effects on the central nervous system. It is a common symptom associated with low sodium levels.
B. Flushed skin
Flushed skin is not typically associated with hyponatremia. This is more commonly seen in conditions such as fever, inflammation, or allergic reactions.
C. Extreme thirst
Extreme thirst is more associated with hypernatremia (high sodium levels) rather than hyponatremia. In hyponatremia, the client might have a reduced sensation of thirst or might experience symptoms related to fluid overload. .
D. Fever
Fever is not a direct symptom of hyponatremia. It can be associated with infections or inflammatory conditions, but it is not a typical manifestation of low sodium levels.
Full Explanation
A. Severe hyponatremia can cause nausea and vomiting due to the disturbance in electrolyte balance and the effects on the central nervous system. It is a common symptom associated with low sodium levels.
B. Flushed skin is not typically associated with hyponatremia. This is more commonly seen in conditions such as fever, inflammation, or allergic reactions.
C. Extreme thirst is more associated with hypernatremia (high sodium levels) rather than hyponatremia. In hyponatremia, the client might have a reduced sensation of thirst or might experience symptoms related to fluid overload.
D. Fever is not a direct symptom of hyponatremia. It can be associated with infections or inflammatory conditions, but it is not a typical manifestation of low sodium levels.
A nurse is assisting with teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?
A. Bedwetting
Bedwetting, also known as nocturnal enuresis, can be a physiological change in older adult clients due to changes in bladder control. It is important to address this issue with sensitivity and provide appropriate management strategies. Older adults may experience feelings of shame or embarrassment due to age-related changes in their physical appearance or functional abilities. It is essential to address these emotional aspects and provide support and reassurance to older adults. However, this is not necessarily a physiological change. Inability to form healthy relationships: While some older adults may struggle with forming new relationships due to various factors, it is not an expected physiological change. The ability to form relationships can vary among individuals based on their social environment, life experiences, and personal characteristics. Overeating is not an expected physiological change in older adults. However, older adults may experience changes in appetite or nutritional needs, which can lead to alterations in eating patterns. It is important to promote healthy eating habits and address any specific dietary concerns related to aging.
B. Feelings of shame
C. Inability to form healthy relationships
D. Overeating