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 C
Explanation
(A) Limit the client’s visitors to one at a time: While it’s important to maintain a peaceful environment for the client, limiting visitors may not be necessary unless the client’s condition is being negatively affected by too many visitors or if there are restrictions due to infection control.
(B) Avoid touching the client: Touch can be a powerful form of communication, especially when a client is unresponsive. Gentle touch can convey caring and presence, so avoiding touch is not typically recommended unless there’s a specific reason to do so (like if the client is in pain).
(C) Continue to talk to the client as if they are alive: This is the most appropriate answer. Even if a client is unresponsive, they may still be able to hear and understand. Continuing to talk to the client can provide comfort and reassurance.
(D) Whisper when talking in the client’s room: Whispering is not necessary and can even be confusing or distressing for the client. It’s better to speak in a normal, calm, and reassuring voice.
Correct Answer is ["A","D"]
Explanation
A. Review strategies to reduce sodium intake:
This educational method involves providing information and teaching the client specific strategies to reduce sodium intake, such as reading food labels, avoiding high-sodium processed foods, and choosing fresh fruits and vegetables. It engages the cognitive domain of learning as it focuses on acquiring knowledge and understanding of the topic.
B. Ask the client how they are feeling about starting a low sodium diet:
This educational method involves exploring the client's feelings and emotions regarding the low sodium diet. It primarily engages the affective domain of learning, which focuses on attitudes, beliefs, and feelings.
C. Observe the client choose low sodium foods:
This educational method involves observing the client's behavior and actions. It primarily engages the psychomotor domain of learning, which focuses on physical skills and actions.
D. Discuss the physiology of hypertension with the client:
This educational method involves explaining the underlying physiology of hypertension, including factors such as sodium intake, blood pressure regulation, and cardiovascular health. It engages the cognitive domain of learning as it focuses on acquiring knowledge and understanding of the physiological processes involved in hypertension.
E. Encourage the client to share their thoughts in a support group:
This educational method involves providing opportunities for the client to share their thoughts and experiences with others in a support group setting. It primarily engages the affective domain of learning, which focuses on attitudes, beliefs, and feelings.
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