A nurse is reviewing the ABG values of a client who has chronic bronchitis and reports dyspnea with minimal exertion. Which of the following acid- base imbalances should the nurse suspect?
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
The Correct Answer is C
Answer: C. Respiratory acidosis
Rationale:
A) Metabolic acidosis: This occurs when there is an excess of acid in the body or a loss of bicarbonate, often due to conditions such as renal failure or severe diarrhea. In chronic bronchitis, the primary issue is related to respiratory function rather than metabolic disturbances.
B) Respiratory alkalosis: This condition results from hyperventilation, leading to excessive loss of carbon dioxide. It is unlikely in a client with chronic bronchitis, who typically experiences difficulty in exhaling fully rather than hyperventilating.
C) Respiratory acidosis: In chronic bronchitis, airflow obstruction and reduced gas exchange can lead to carbon dioxide retention, resulting in respiratory acidosis. Symptoms like dyspnea and increased work of breathing support this imbalance, as the body is unable to adequately expel carbon dioxide.
D) Metabolic alkalosis: This imbalance results from excessive bicarbonate or loss of hydrogen ions, often related to prolonged vomiting or diuretics. It is not characteristic of chronic bronchitis, where the primary concern is respiratory function rather than metabolic processes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(A) Determine the client’s blood pressure 1 min after each position change: While it’s important to check the client’s blood pressure after each position change when assessing for orthostatic hypotension, this is not the first step. The nurse should first establish a baseline blood pressure reading with the client in a supine position.
(B) Place the client in a sitting position: Although the nurse will eventually need to check the client’s blood pressure in a sitting position, the first step is to get a baseline reading with the client in a supine position.
(C) Assist the client into a standing position: The nurse will eventually assist the client into a standing position to check for changes in blood pressure, but this is not the first step. The initial step is to get a baseline reading with the client in a supine position.
(D) Check the blood pressure with the client in a supine position: This is the most appropriate first step. When checking for orthostatic hypotension, the nurse should first check the client’s blood pressure while they are lying flat (supine). This provides a baseline reading against which subsequent readings (taken when the client is sitting and standing) can be compared. If there’s a significant drop in blood pressure upon standing, this could indicate orthostatic hypotension.
Correct Answer is C
Explanation
(A) Treatment: While treatment is an important part of the client’s information, it is typically included in the “Recommendation” component of ISBARR, where the nurse would discuss the recommended treatment plan.
(B) List of medications: The list of medications a client is taking is crucial information, but it is usually included in the “Background” component of ISBARR, which provides context about the client’s medical history and current medications.
(C) Medical condition: This is the most appropriate answer. The “Situation” component of ISBARR is meant to provide a brief overview of the client’s current situation, which includes their current medical condition or reason for admission.
(D) Vital signs: Vital signs are typically included in the “Assessment” component of ISBARR, where the nurse would discuss the results of their assessment of the client, including vital signs.
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