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 D
Explanation
Choice A Reason:
“Call the provider” is important but not the first priority. The immediate concern is to maintain the client’s intravenous access to ensure they can receive any necessary medications or fluids promptly. Once the line is secured, the provider should be notified to receive further instructions and manage the client’s condition.
Choice B Reason:
“Notify the blood bank” is also crucial but comes after ensuring the client’s immediate safety. The blood bank needs to be informed to investigate the cause of the reaction and prevent further issues, but this step follows the initial emergency interventions.
Choice C Reason:
“Collect a urine specimen” is necessary to check for hemolysis, which can occur during a transfusion reaction. However, this is not the first step. The priority is to stabilize the client by maintaining IV access with normal saline.
Choice D Reason:
“Keep the line open with 0.9% NS through new tubing” is the correct first intervention. This action ensures that the client remains hydrated and that the IV line is available for any emergency medications or treatments. Using new tubing prevents any contamination from the transfusion set.
Correct Answer is C
Explanation
Choice A Reason:
Hyperkalosis is incorrect. Hyperkalosis refers to an elevated level of potassium in the blood, which is not directly related to the pH level. While hyperkalemia can occur in acidosis, it is not the primary condition indicated by a low pH
Choice B Reason:
Hyponatremia is incorrect. Hyponatremia refers to low sodium levels in the blood. It does not directly affect the pH level and is not indicated by the pH value provided.
Choice C Reason:
Acidosis is correct. The normal pH range for arterial blood is 7.35 to 7.45. A pH of 7.10 is below this range, indicating that the blood is too acidic. This condition is known as acidosis.
Choice D Reason:
Alkalosis is incorrect. Alkalosis refers to a condition where the blood pH is higher than the normal range, indicating that the blood is too basic. A pH of 7.10 is too low, not too high, and therefore indicates acidosis.
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