A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min.
Which of the following acid-base imbalances should the nurse expect?
Metabolic acidosis.
Respiratory alkalosis.
Metabolic alkalosis.
Respiratory acidosis.
The Correct Answer is D
Choice A rationale:
A respiratory rate of 9/min and shallow respirations are indicative of hypoventilation, which can lead to an accumulation of carbon dioxide (CO2) in the blood. This condition results in respiratory acidosis (Choice D). In respiratory acidosis, the arterial pH is decreased (acidic) while the PaCO2 (partial pressure of carbon dioxide) is elevated.
Choice B rationale:
Respiratory alkalosis (Choice B) is characterized by a low PaCO2 and an elevated pH due to hyperventilation. Shallow respirations and a respiratory rate of 9/min do not align with this condition, as it typically involves rapid and deep breathing.
Choice C rationale:
Metabolic alkalosis (Choice C) results from a primary excess of bicarbonate (HCO3-) in the blood and is not associated with the given respiratory patterns. Shallow respirations and a low respiratory rate are more likely to lead to an accumulation of CO2, causing respiratory acidosis (Choice D).
Choice D rationale:
The correct answer is choice D. Shallow respirations and a respiratory rate of 9/min indicate hypoventilation, leading to an accumulation of CO2 in the blood. This condition results in respiratory acidosis, where the arterial pH is decreased. The body's compensatory response is to retain bicarbonate to normalize pH, but this can result in an elevated HCO3- level. The primary acid-base imbalance in this case is respiratory acidosis. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"I can plan to eat rice instead of baked potatoes.”. This choice demonstrates an understanding of dietary sources of potassium. Baked potatoes are a good source of potassium, and the client's willingness to substitute rice for baked potatoes indicates that they are aware of alternative potassium-rich foods. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. The client's willingness to make a dietary adjustment is a positive sign.
Choice B rationale:
"Adding pecans will be a change I can readily make.”. While pecans are a good source of potassium, this choice does not directly address the client's ability to substitute a potassium-rich food for one they might need to avoid. It focuses on a new addition to their diet rather than a substitution, making it a less relevant response to the teaching.
Choice C rationale:
"I will eat cantaloupe for my morning snack.”. Cantaloupe is indeed a good source of potassium, but this choice does not indicate an understanding of how to substitute potassium-rich foods in their diet. It only mentions adding cantaloupe as a snack without addressing the potential need for replacing other foods high in potassium. Therefore, it does not fully demonstrate comprehension of the teaching.
Choice D rationale:
"I will miss eating yogurt every day for breakfast.”. This choice expresses a sentiment but does not show an understanding of the teaching regarding dietary sources of potassium. It merely states that the client will miss yogurt without providing any insight into their ability to make appropriate dietary choices to maintain adequate potassium intake.
Correct Answer is A
Explanation
Choice A rationale:
Restricting visitation is an essential intervention during an influenza outbreak in a long-term care facility. Influenza is highly contagious and can spread rapidly among residents and staff in a close environment like a long-term care facility. By limiting visitation, the facility can reduce the risk of introducing the virus from the outside and help contain the outbreak. This is a preventive measure to protect vulnerable residents from exposure to the virus.
Choice B rationale:
Providing prophylactic antibiotics for clients who have been exposed to influenza is not a recommended intervention. Influenza is caused by a virus, not bacteria, so antibiotics are ineffective in preventing or treating the infection. Antibiotics should only be used to treat bacterial infections, not viral ones. Inappropriate use of antibiotics can lead to antibiotic resistance and other adverse effects.
Choice C rationale:
Implementing airborne precautions for clients who have influenza is not typically necessary. Influenza primarily spreads through respiratory droplets when an infected person coughs or sneezes. Standard precautions, such as proper hand hygiene and wearing masks when in close contact with infected individuals, are usually sufficient to prevent the spread of the virus. Airborne precautions are typically reserved for diseases that are transmitted through the airborne route, like tuberculosis.
Choice D rationale:
Assigning healthcare personnel to nondirect care activities for 24 hours after developing influenza symptoms is not a recommended intervention. While it's important for healthcare personnel to stay home when they are sick to prevent the spread of the virus, 24 hours may not be a necessary duration. The standard guideline for healthcare workers with influenza is to stay home until they are fever-free for at least 24 hours without the use of fever-reducing medications.
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