A nurse is caring for a client in the emergency department (ED) who has high anxiety and shallow respirations at a rate of 30/min. Which of the following acid-base disturbances is the client most likely experiencing?

Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

A. Respiratory acidosis occurs due to hypoventilation, resulting in carbon dioxide retention. This condition is characterized by slow, shallow breathing and confusion, which is not consistent with the client's rapid respiratory rate of 30/min.
B. Respiratory alkalosis is typically caused by hyperventilation, where excessive breathing leads to a decrease in carbon dioxide levels. The client's symptoms of high anxiety and rapid, shallow respirations are indicative of hyperventilation, making respiratory alkalosis the most likely diagnosis.
C. Metabolic acidosis is characterized by deep, rapid breathing (Kussmaul respirations) as the body attempts to expel excess acid. The client's shallow respirations are inconsistent with the breathing pattern seen in metabolic acidosis.
D. Metabolic alkalosis usually presents with symptoms such as dizziness and tingling, often with compensatory slow respirations. The rapid respiratory rate in this case does not suggest metabolic alkalosis, making this option unlikely.

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Correct Answer is B

Explanation

A. Respiratory acidosis is caused by hypoventilation, leading to an increase in carbon dioxide levels in the blood. This condition is characterized by confusion, drowsiness, and headache, but it does not typically present with vomiting, tingling, or slow respirations as described in this scenario.
B. Metabolic alkalosis occurs due to a loss of hydrogen ions or an excess of bicarbonate, commonly caused by prolonged vomiting. The symptoms described, including persistent vomiting, tingling, and slow, shallow respirations, are consistent with metabolic alkalosis.
C. Metabolic acidosis results from the accumulation of acid or loss of bicarbonate, often presenting with rapid, deep breathing (Kussmaul respirations). The client’s slow respirations and other symptoms do not align with metabolic acidosis, making this option less likely.
D. Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide levels. It is usually associated with rapid breathing and does not match the slow respirations and other symptoms seen in this client.

A. Diarrhea B. Vomiting C. Salicylate intoxication D. Hyperventilation

Correct Answer is A

Explanation

A. Diarrhea: Diarrhea leads to the loss of bicarbonate, an important buffer in the blood, which can contribute to the development of metabolic acidosis as the body loses bicarbonate faster than it can replace it.

B. Vomiting: Vomiting typically leads to metabolic alkalosis due to the loss of stomach acid, which reduces the amount of hydrogen ions in the body.

C. Salicylate intoxication: This condition primarily causes a mixed acid-base disturbance, including metabolic acidosis and respiratory alkalosis, due to its effects on both the metabolic and respiratory systems.

D. Hyperventilation: This condition causes respiratory alkalosis due to excessive loss of carbon dioxide, not metabolic acidosis.

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A nurse is caring for a client in the emergency department (ED) who has high anxiety and shallow respirations at a rate of 30/min. Which of the following acid-base disturbances is the client most likely experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who has metabolic acidosis. The nurse should realize that which of the following findings contributes to the development of metabolic acidosis?

Correct Answer is A

Explanation

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