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?
Metabolic acidosis
Respiratory alkalosis
Metabolic alkalosis
Respiratory acidosis
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is C
Explanation
A.Medications and blood should never be mixed in the same line because it can cause reactions, interference with the blood product, and complications for the client. Medications should be administered through a separate IV line or a port further away from the client.
B.Blood transfusions should typically be completed within 2 to 4 hours to reduce the risk of bacterial contamination and ensure that the blood does not exceed a safe infusion duration.
C.Y tubing is commonly used for blood transfusions, where one arm of the Y is used for the packed RBCs and the other is for normal saline. Normal saline is used to flush the line before and after administering blood, ensuring the infusion is free of air and that the blood flows smoothly without clotting.
D.The drip chamber should not be completely filled with blood. It should have a small amount of blood for monitoring the infusion rate, but the filter within the drip chamber is designed to filter any clots or debris. A completely filled chamber with blood can make it difficult to assess the flow rate, and could indicate that the blood is not flowing properly.
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