A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid- base imbalances?

Metabolic acidosis

Respiratory alkalosis

Metabolic alkalosis

Respiratory acidosis

Answer and Explanation

The Correct Answer is C

C. Metabolic alkalosis is characterized by an increase in serum bicarbonate levels, resulting in an imbalance in the body's acid-base equilibrium towards alkalinity. Excessive ingestion of antacids, particularly those containing bicarbonate or calcium carbonate, can lead to an excessive accumulation of bicarbonate ions in the body, causing metabolic alkalosis.
A. Excessive ingestion of antacids would not typically cause metabolic acidosis because antacids containing bicarbonate or calcium carbonate actually increase bicarbonate levels, leading to alkalosis rather than acidosis.
B. Respiratory alkalosis occurs due to hyperventilation, leading to a decrease in carbon dioxide levels and subsequent alkalosis. Excessive ingestion of antacids is not typically associated with respiratory alkalosis.

D. Respiratory acidosis occurs due to hypoventilation, leading to an increase in carbon dioxide levels and subsequent acidosis. Excessive ingestion of antacids is not typically associated with respiratory acidosis.

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Correct Answer is C

Explanation

C. When collecting a stool specimen from a client with Clostridium difficile infection, the nurse should wear gloves to prevent the spread of the bacteria to themselves and other patients. Proper hand hygiene should also be performed after glove removal.
A. While alcohol-based hand rubs are effective against many types of bacteria and viruses, they are not effective against Clostridium difficile spores. Handwashing with soap and water is recommended for hand hygiene in cases of Clostridium difficile infection, as it is more effective at removing spores from the hands.
B. Chlorhexidine is a disinfectant commonly used for skin antisepsis, but it is not effective against
D. Placing the client in a protective environment is not typically necessary for clients with Clostridium difficile gastroenteritis unless they are immunocompromised or have other conditions that require protective isolation.

A. Apply mitten restraints to prevent the client from disconnecting their tube feeding. B. Apply a vest restraint daily at bedtime to prevent nighttime wandering. C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation. D. Apply soft heel protectors bilaterally while client is in bed.

Correct Answer is B

Explanation

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

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A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid- base imbalances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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