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 D
Explanation
Choice A reason: You should not expect your stoma to be a purple color. A purple stoma indicates ischemia or necrosis, which are serious complications that require immediate medical attention. A healthy stoma should be pink or red and moist.
Choice B reason: Your colostomy will produce formed stool, depending on the location of the colostomy. A sigmoid colostomy is located in the lower part of the large intestine, where most of the water is absorbed from the stool. Therefore, the stool from a sigmoid colostomy will be more solid and regular than from other types of colostomies.
Choice C reason: The end of the stoma will not be painful after this procedure. The stoma is made from the lining of the intestine, which does not have nerve endings that sense pain. However, the skin around the stoma may be sore or irritated from the surgery or the appliance.
Choice D reason: You will have a stoma in your left lower abdomen. A sigmoid colostomy is created by bringing the end of the sigmoid colon, which is the last segment of the large intestine, through an opening in the left lower quadrant of the abdomen. The stoma is then attached to the skin and covered with an appliance that collects the stool.
Correct Answer is D
Explanation
Choice A reason: Stripping the client's chest tube every 2 hours is not a recommended action, as it can cause excessive negative pressure, tissue trauma, and pain. The nurse should only strip the chest tube if there is a clot or obstruction in the tubing, and only with the provider's order.
Choice B reason: Looping the tubing of the chest tube on the client's bed is a correct action, as it prevents kinking, tension, or pulling on the chest tube. The nurse should also secure the tubing to the bed sheet with a safety pin.
Choice C reason: Placing the chest tube drainage system above the level of the client's heart is not a correct action, as it can cause the fluid to flow back into the chest cavity and impair lung expansion. The nurse should place the chest tube drainage system below the level of the client's chest.
Choice D reason: Taping the connections on the client's chest tube is a correct action, as it prevents air leaks, disconnections, or accidental removal of the chest tube. The nurse should also check the connections regularly for tightness and patency.
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