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 B
Explanation
Choice A rationale:
Chloride 99 mEq/L. Rationale: A chloride level of 99 mEq/L is within the normal range, which is typically around 96-106 mEq/L. There is no need to report this value to the provider as it is not indicative of a significant abnormality.
Choice C rationale:
Magnesium 1.9 mg/dL. Rationale: A magnesium level of 1.9 mg/dL is within the normal range, which is generally about 1.5-2.5 mg/dL. This value is not indicative of a significant abnormality and does not require immediate reporting to the provider.
Choice D rationale:
Potassium 3.6 mEq/L. Rationale: A potassium level of 3.6 mEq/L is within the normal range, which is typically around 3.5-5.0 mEq/L. While it's on the lower side of the normal range, it is not low enough to warrant immediate reporting to the provider. However, the nurse should continue to monitor the client's potassium levels and address any potential issues if they persist or worsen.
Choice B rationale:
Sodium 126 mEq/L. Rationale: A sodium level of 126 mEq/L is below the normal range, which is typically around 135-145 mEq/L. Hyponatremia, or low sodium levels, can be a serious condition that can lead to neurological symptoms and other complications. Therefore, the nurse should promptly report this finding to the provider so that appropriate interventions can be initiated.
Correct Answer is C
Explanation
Choice A rationale:
Taking hydrochlorothiazide on an empty stomach is not a requirement for this medication. Hydrochlorothiazide is a diuretic used to treat conditions like hypertension and edema. It can be taken with or without food, and food may help reduce stomach upset for some individuals.
Choice B rationale:
Muscle weakness is an adverse effect of hydrochlorothiazide. Therefore, it is not an expected outcome. Hydrochlorothiazide is a thiazide diuretic, and one of its common side effects is potassium loss through increased urine output. This can lead to muscle weakness and cramping. The nurse should educate the client about the signs and symptoms of low potassium and the importance of including potassium-rich foods in their diet.
Choice C rationale:
Increasing daily intake of foods high in potassium is essential information to include in the teaching for a client taking hydrochlorothiazide. Thiazide diuretics like hydrochlorothiazide can cause potassium depletion, which may result in adverse effects like muscle weakness, cramping, and cardiac dysrhythmias. Therefore, advising the client to consume potassium-rich foods, such as bananas, oranges, and potatoes, can help counteract the potassium loss associated with the medication.
Choice D rationale:
Taking the medication at bedtime is not a specific requirement for hydrochlorothiazide. Thiazide diuretics can be taken at various times of the day, depending on the client's preferences and when they are most compliant with their medication regimen. The timing of administration should be consistent to maintain the medication's effectiveness.
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