A nurse is caring for a client who is unconscious and has a living will. The client's family asks if they can make changes to lifesaving measures now that the client is unconscious. Which of the following statements should the nurse make?

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.

Correct answer: C

A. This action would be appropriate if the potassium level were high, indicating hyperkalemia. However, since the client's potassium level is low, the nurse should administer the KCl as prescribed to address the hypokalemia. If there are any concerns about the rate or method of administration, or if the client shows signs of potassium-related complications, the nurse should then consult the provider.

B.Calling the lab to verify the client's results may seem like a reasonable action, but it's not the most appropriate in this scenario. Serum potassium levels are commonly measured accurately, and the nurse should prioritize clinical judgment based on the current potassium level in conjunction with the client's condition and medication regimen.

C. A serum potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can have serious consequences, including muscle weakness, cardiac arrhythmias, and other complications. Administering potassium chloride (KCl) as prescribed is necessary to correct this deficiency and prevent potential adverse effects associated with low potassium levels.

D.Simply omitting the KCL dose without informing the healthcare provider of the client's low potassium level could lead to a missed opportunity for appropriate intervention. Documenting the omission is essential for accurate record-keeping, but it's crucial to communicate the situation to the provider for further guidance.