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 A

Explanation

A. Cardiac enlargement: Chronic hypoxia leads to increased workload on the heart as it works harder to deliver oxygen to tissues. This can result in cardiac enlargement or right-sided heart failure due to pulmonary hypertension, a common consequence of long-term hypoxia.

B. Exophthalmos: Exophthalmos is protrusion of the eyes and is typically associated with thyroid disorders, such as Graves' disease, rather than chronic hypoxia.

C. Gastric ulcerations: While stress and certain medications can lead to gastric ulcerations, they are not directly caused by chronic hypoxia. Chronic hypoxia mainly affects the cardiovascular and pulmonary systems.

D. Urinary tract infections: Chronic hypoxia does not typically lead to urinary tract infections. UTIs are more commonly associated with factors such as poor hygiene, urinary obstruction, or immunosuppression.

A. Encourage the client to drink more fluids. B. Encourage regular use of the incentive spirometer. C. Encourage coughing and deep breathing. D. Encourage the client to ambulate more often.

Correct Answer is A

Explanation

A. Encourage the client to drink more fluids: Increasing fluid intake helps thin respiratory secretions, making them easier to clear from the lungs. Hydration is crucial in managing pneumonia to help with mucus mobilization.

B. Encourage regular use of the incentive spirometer: While the incentive spirometer helps with lung expansion and preventing atelectasis, it does not directly affect the viscosity of secretions.

C. Encourage coughing and deep breathing: Coughing and deep breathing are important for clearing secretions, but they are more effective once the secretions are already thin. Drinking fluids is a more direct method to thin the secretions.

D. Encourage the client to ambulate more often: Ambulation is beneficial for overall respiratory health and lung function, but it does not directly thin respiratory secretions. Increasing fluid intake is more effective for this purpose.

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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

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Correct Answer is A

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Correct Answer is A

Explanation

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