A nurse is caring for a client who has nausea and is vomiting. The nurse should identify that the client is at risk for which of the following acid-base imbalances?
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
Respiratory alkalosis
The Correct Answer is A
Choice A reason: Metabolic alkalosis is a condition in which the blood pH is elevated due to an excess of bicarbonate or a loss of acid. It can be caused by nausea and vomiting, as they result in the loss of gastric acid and the retention of bicarbonate.
Choice B reason: Respiratory acidosis is a condition in which the blood pH is lowered due to an accumulation of carbon dioxide. It can be caused by hypoventilation, airway obstruction, or lung diseases. It is not related to nausea and vomiting.
Choice C reason: Metabolic acidosis is a condition in which the blood pH is lowered due to an excess of acid or a loss of bicarbonate. It can be caused by diabetic ketoacidosis, renal failure, or lactic acidosis. It is not caused by nausea and vomiting.
Choice D reason: Respiratory alkalosis is a condition in which the blood pH is elevated due to a loss
carbon dioxide. It can be caused by hyperventilation, anxiety, fever, or aspirin overdose. It is not common in clients who have nausea and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Collecting urine from the catheter's port is not a correct action for the nurse to take, as it can introduce contamination and infection into the urinary tract. The nurse should insert a new, sterile catheter into the bladder and collect the urine directly from the catheter.
Choice B reason: Using a sterile specimen container is a correct action for the nurse to take, as it ensures that the urine sample is not contaminated by any bacteria or other substances. The nurse should label the container with the client's name, date, and time of collection and send it to the laboratory as soon as possible.
Choice C reason: Using sterile water to inflate the balloon is not a relevant action for the nurse to take, as it applies to an indwelling catheter, not a straight catheter. A straight catheter does not have a balloon and is removed after the urine is drained.
Choice D reason: Instructing the client to clean from front to back with an antiseptic solution is a good action for the nurse to take, as it helps to prevent the introduction of bacteria from the anal area into the urethra. However, it is not the best answer, as it is a general hygiene measure, not a specific action for obtaining a urine specimen.
Correct Answer is B
Explanation
Choice A reason: Planning to administer insulin to the client is not a relevant action for the nurse to take, as it has no effect on respiratory alkalosis or hyperventilation. Insulin is used to lower blood glucose levels in patients with diabetes or hyperglycemia.
Choice B reason: Having the client breathe into a paper bag is a correct action for the nurse to take, as it helps to increase the carbon dioxide level in the blood and correct the alkalosis. Breathing into a paper bag creates a closed system that recycles the exhaled carbon dioxide and reduces the loss of carbon dioxide from the lungs.
Choice C reason: Planning to administer sodium bicarbonate to the client is not a correct action for the nurse to take, as it can worsen the alkalosis. Sodium bicarbonate is an alkali that can raise the pH of the blood and cause metabolic alkalosis. It is used to treat metabolic acidosis, not respiratory alkalosis.
Choice D reason: Having the client place their head between their knees is not a recommended action for the nurse to take, as it can impair the blood flow to the brain and cause fainting. It can also increase the respiratory rate and decrease the carbon dioxide level in the blood.
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