A nurse is caring for a patient who is experiencing nausea and vomiting.
The nurse should identify that the patient is at risk for which of the following acid-base imbalances?
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
Respiratory alkalosis
The Correct Answer is A
Choice A rationale:
Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid. When a person vomits, they lose hydrochloric acid, and the loss of this acid can cause the blood to become more basic. This shift in pH can lead to metabolic alkalosis, a condition characterized by high levels of bicarbonate in the blood, which makes it more alkaline (or less acidic). Symptoms of metabolic alkalosis can include muscle twitching, hand tremor, nausea or vomiting, and tingling in the face, hands or feet. In severe cases, it can cause prolonged muscle contractions or seizures.
Choice B rationale:
Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2) from the body, which causes the body’s fluids, especially the blood, to become too acidic. This can occur due to conditions that affect the lungs such as chronic obstructive pulmonary disease (COPD), asthma, or sleep apnea. However, in the case of a patient experiencing nausea and vomiting, respiratory acidosis is less likely to be the primary concern.
Choice C rationale:
Metabolic acidosis occurs when the body produces too much acid, or when the kidneys aren’t removing enough acid from the body. This can be caused by conditions such as kidney disease, lactic acidosis, or ketoacidosis. In the case of a patient experiencing nausea and vomiting, the primary concern would not typically be metabolic acidosis, as vomiting leads to a loss of stomach acid, which would more likely result in a state of alkalosis, not acidosis.
Choice D rationale:
Respiratory alkalosis is a condition that occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to rise and become too alkaline. When the blood is too alkaline, it means that it is not carrying enough carbon dioxide. This condition can be caused by fever, hyperventilation, or lack of oxygen. In the case of a patient experiencing nausea and vomiting, respiratory alkalosis is not typically the primary concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.
Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.
Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.
Correct Answer is C
Explanation
Choice A rationale:
Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced. It occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This condition does not directly cause dry skin.
Choice B rationale:
Abdominal pain is not a common symptom of respiratory alkalosis. The condition is usually caused by over-breathing (called hyperventilation) that occurs when you breathe very deeply or rapidly. While it can cause discomfort, it does not typically result in abdominal pain.
Choice C rationale:
Diarrhea is not a direct symptom of respiratory alkalosis. However, the stress or anxiety that can cause hyperventilation and lead to respiratory alkalosis might also upset the digestive system and cause diarrhea. It’s important to note that while stress and anxiety can cause both conditions, they are not a direct result of the respiratory alkalosis itself.
Choice D rationale:
Flank pain is not a symptom of respiratory alkalosis. Flank pain is often associated with kidney problems, not respiratory conditions. Respiratory alkalosis is characterized by symptoms such as dizziness, bloating, feeling light-headed, numbness or muscle spasms in the hands and feet, discomfort in the chest area, confusion, dry mouth, tingling in the arms, heart palpitations, and feeling short of breath.
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