Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for respiratory alkalosis?
A. A client who is taking a thiazide diuretic.
Thiazide diuretics cause potassium and chloride loss, leading to metabolic alkalosis, not respiratory alkalosis. Hypokalemia decreases hydrogen ion excretion, increasing bicarbonate levels. Metabolic alkalosis is characterized by pH >7.45 and HCO₃⁻ >26 mEq/L rather than decreased PaCO₂.
B. A client who is vomiting.
Vomiting leads to metabolic alkalosis due to gastric acid loss. Hydrogen ion depletion increases bicarbonate concentration, shifting pH above normal. Arterial blood gases typically show increased HCO₃⁻ (>26 mEq/L) with a compensatory increase in PaCO₂ (>45 mmHg), not respiratory alkalosis.
C. A client who has salicylate intoxication.
Salicylate intoxication initially induces hyperventilation, reducing PaCO₂ levels below 35 mmHg and increasing pH above 7.45, leading to respiratory alkalosis. As toxicity progresses, metabolic acidosis may develop due to lactic acid accumulation, but early stages primarily present with respiratory alkalosis.
D. A client who has hypoventilation.
Hypoventilation leads to CO₂ retention, increasing PaCO₂ above 45 mmHg, forming carbonic acid (H₂CO₃) and causing respiratory acidosis. Blood gases show pH <7.35 with elevated PaCO₂, not respiratory alkalosis, which is caused by excessive CO₂ elimination through hyperventilation.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn 2019 NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is Choice C.
Choice A rationale: Thiazide diuretics cause potassium and chloride loss, leading to metabolic alkalosis, not respiratory alkalosis. Hypokalemia decreases hydrogen ion excretion, increasing bicarbonate levels. Metabolic alkalosis is characterized by pH >7.45 and HCO₃⁻ >26 mEq/L rather than decreased PaCO₂.
Choice B rationale: Vomiting leads to metabolic alkalosis due to gastric acid loss. Hydrogen ion depletion increases bicarbonate concentration, shifting pH above normal. Arterial blood gases typically show increased HCO₃⁻ (>26 mEq/L) with a compensatory increase in PaCO₂ (>45 mmHg), not respiratory alkalosis.
Choice C rationale: Salicylate intoxication initially induces hyperventilation, reducing PaCO₂ levels below 35 mmHg and increasing pH above 7.45, leading to respiratory alkalosis. As toxicity progresses, metabolic acidosis may develop due to lactic acid accumulation, but early stages primarily present with respiratory alkalosis.
Choice D rationale: Hypoventilation leads to CO₂ retention, increasing PaCO₂ above 45 mmHg, forming carbonic acid (H₂CO₃) and causing respiratory acidosis. Blood gases show pH <7.35 with elevated PaCO₂, not respiratory alkalosis, which is caused by excessive CO₂ elimination through hyperventilation.
Similar Questions
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?
A. Increased fetal movement.
Increased fetal movement is a positive sign during pregnancy and indicates the well-being of the baby. It is not a concern and does not require reporting.
B. Increased urinary output.
Increased urinary output may be expected in a client receiving magnesium sulfate due to its diuretic effects. This finding is not alarming and does not require immediate reporting unless it is associated with other concerning symptoms.
C. Increased muscle weakness.
Increased muscle weakness is a potential side effect of magnesium sulfate administration. It is important to monitor the client for signs of magnesium toxicity, and increased muscle weakness should be reported promptly as it may indicate the need for adjustments in the dosage or administration of the medication.
D. Increased respiratory rate.
Increased respiratory rate is not typically associated with magnesium sulfate use and is unlikely to be a concerning finding in this context. However, it's always essential to monitor respiratory status, but it may not be specifically related to the magnesium sulfate treatment.
Full Explanation
Choice A rationale:
Increased fetal movement is a positive sign during pregnancy and indicates the well-being of the baby. It is not a concern and does not require reporting.
Choice B rationale:
Increased urinary output may be expected in a client receiving magnesium sulfate due to its diuretic effects. This finding is not alarming and does not require immediate reporting unless it is associated with other concerning symptoms.
Choice C rationale:
Increased muscle weakness is a potential side effect of magnesium sulfate administration. It is important to monitor the client for signs of magnesium toxicity, and increased muscle weakness should be reported promptly as it may indicate the need for adjustments in the dosage or administration of the medication.
Choice D rationale:
Increased respiratory rate is not typically associated with magnesium sulfate use and is unlikely to be a concerning finding in this context. However, it's always essential to monitor respiratory status, but it may not be specifically related to the magnesium sulfate treatment.
A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect?
A. Bright, red vaginal discharge.
Bright, red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Instead, it can be indicative of other conditions such as miscarriage or vaginal bleeding.
B. Scaphoid abdomen.
A scaphoid abdomen is not a typical manifestation of an ectopic pregnancy. A scaphoid abdomen is seen in cases of diaphragmatic hernia, where the abdominal organs move into the chest cavity, leaving the abdomen with a sunken appearance.
C. Elevated blood pressure.
Elevated blood pressure is not a typical manifestation of an ectopic pregnancy. High blood pressure can be associated with conditions like preeclampsia but is not specifically linked to ectopic pregnancies.
D. Sharp pelvic pain.
Sharp pelvic pain is a common manifestation of an ectopic pregnancy. As the fertilized egg implants outside the uterus, often in the fallopian tube, it can cause pain and discomfort.
Full Explanation
Choice A rationale:
Bright, red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Instead, it can be indicative of other conditions such as miscarriage or vaginal bleeding.
Choice B rationale:
A scaphoid abdomen is not a typical manifestation of an ectopic pregnancy. A scaphoid abdomen is seen in cases of diaphragmatic hernia, where the abdominal organs move into the chest cavity, leaving the abdomen with a sunken appearance.
Choice C rationale:
Elevated blood pressure is not a typical manifestation of an ectopic pregnancy. High blood pressure can be associated with conditions like preeclampsia but is not specifically linked to ectopic pregnancies.
Choice D rationale:
Sharp pelvic pain is a common manifestation of an ectopic pregnancy. As the fertilized egg implants outside the uterus, often in the fallopian tube, it can cause pain and discomfort.
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?
A. Position the client in a knee-chest position.
Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.
B. Administer a bolus infusion of lactated Ringer's.
Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.
C. Give terbutaline subcutaneously.
Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.
D. Apply oxygen via a nonrebreather face mask at 2 L/min.
Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.
Full Explanation
The correct answer is choice B: Administer a bolus infusion of lactated Ringer’s.
Choice A rationale:
Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.
Choice B rationale:
Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.
Choice C rationale:
Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.
Choice D rationale:
Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.