How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-base imbalances should the nurse identify the client as being at risk for developing initially?

A.

Metabolic acidosis

B.

Respiratory alkalosis

C.

Metabolic alkalosis

D.

Respiratory acidosis

Answer and Explanation

The Correct Answer is D

Correct answer: D

A. Metabolic acidosis occurs due to either increased production of metabolic acids, such as lactic acid in anaerobic metabolism, or decreased excretion of acids, such as in renal failure.Shallow respirations would not directly cause metabolic acidosis. While they may decrease the elimination of CO2, resulting in respiratory acidosis, they do not directly affect metabolic acid-base balance.

B. Respiratory alkalosis occurs when there is excessive elimination of CO2 from the body, leading to decreased levels of carbonic acid (H2CO3) in the blood. Shallow respirations would not typically lead to excessive elimination of CO2; instead, they would likely result in CO2 retention, leading to respiratory acidosis rather than respiratory alkalosis.

C. Metabolic alkalosis occurs due to excessive loss of acids or increased levels of bicarbonate (HCO3-) in the blood, often caused by conditions such as vomiting, excessive diuretic use, or excessive bicarbonate intake.Shallow respirations would not directly cause metabolic alkalosis. Again, while they may decrease CO2 elimination and lead to respiratory acidosis, they do not directly affect metabolic acid-base balance.

D.Respiratory acidosis occurs when the lungs cannot remove enough of the carbon dioxide (CO2) produced by the body. Shallow respirations lead to inadequate elimination of CO2, causing it to accumulate in the bloodstream. This accumulation of CO2 results in an increase in carbonic acid (H2CO3) in the blood, leading to a decrease in blood pH and resulting in respiratory acidosis.

Therefore, the nurse should identify the client as being at risk for developing respiratory acidosis initially due to the shallow respirations of 9/min.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

Hypokalemia refers to low levels of potassium in the blood. Potassium is an essential electrolyte that plays a crucial role in nerve and muscle cell functioning. When potassium levels are low, it can lead to muscle weakness or even muscle cramps.

Hypertension (high blood pressure) is not commonly associated with hypokalemia. In fact, hypokalemia can sometimes cause low blood pressure (hypotension).

Hyperactive bowel sounds are more commonly associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction. While diarrhea can contribute to electrolyte imbalances, it is not a specific manifestation of hypokalemia.


Cerebral edema refers to swelling in the brain and is not typically associated with hypokalemia. Hypokalemia is more likely to affect muscle and nerve function rather than cerebral edema.

Correct Answer is ["56"]

Explanation

To calculate the infusion rate in gtt/min, we need to know the total number of drops (gtt) needed

for the entire infusion and the time it takes to complete the infusion. Given:

  • Ringer's lactate: 500 mL
  • Infusion time: 3 hours
  • Drop factor: 20 gtt/mL

First, let's calculate the total number of drops needed for the entire infusion: Total drops = Volume (mL) × Drop factor (gtt/mL)

Total drops = 500 mL × 20 gtt/mL Total drops = 10,000 gtt

Next, we need to determine the infusion rate in gtt/min. Since the infusion time is given in hours, we need to convert it to minutes:

Infusion time (min) = Infusion time (hours) × 60 min/hour Infusion time (min) = 3 hours × 60 min/hour

Infusion time (min) = 180 min

Now, we can calculate the infusion rate in gtt/min:

Infusion rate (gtt/min) = Total drops / Infusion time (min) Infusion rate (gtt/min) = 10,000 gtt / 180 min

Infusion rate (gtt/min) ≈ 55.6 gtt/min (Rounded off- 56 gtt/min)

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register