A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
Metabolic alkalosis
The Correct Answer is B
Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.
Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.
Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.
Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
“I will keep spare crutch tips handy.” This statement is correct and indicates good practice. Keeping spare crutch tips handy ensures that the client can replace worn or damaged tips promptly, maintaining the safety and effectiveness of the crutches.
Choice B Reason:
“I will inspect my crutches every day for signs of wear.” This statement is also correct. Regular inspection of crutches for signs of wear and tear helps prevent accidents and ensures that the crutches remain in good working condition.
Choice C Reason:
“I will bear the weight of my body on my axillas.” This statement is incorrect and indicates that the client needs additional education. Bearing weight on the axillas (armpits) can cause nerve damage and discomfort. The correct technique is to support the body’s weight with the hands and arms, not the axillas.
Choice D Reason:
“I will support most of the weight of my body with my arms.” This statement is correct. Supporting the body’s weight with the arms and hands is the proper technique for using crutches, as it prevents nerve damage and ensures better control and stability.
Correct Answer is ["260"]
Explanation
-
Calculation
- Enteral nutrition: 200 mL
- Water flush before feed: 30 mL
- Water flush after feed: 30 mL
Total intake = 200 mL + 30 mL + 30 mL = 260 mL
The nurse should document 260 mL as intake in the I&O.
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