A nurse is taking care of a patient who is nauseous and vomiting.
Which of the following acid-base imbalances should the nurse identify the patient is at risk for?

Respiratory alkalosis.

Metabolic alkalosis.

Metabolic Acidosis.

Respiratory acidosis.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Respiratory alkalosis is typically associated with hyperventilation, which can occur in conditions such as anxiety, fever, or certain lung diseases. However, it is less likely in a patient who is nauseous and vomiting.

Choice B rationale

Metabolic alkalosis is a condition that can occur due to the loss of acid from the body, which can happen when a patient is vomiting. When a person vomits, they lose stomach acid (hydrochloric acid), and this can disrupt the acid-base balance in the body, leading to metabolic alkalosis.

Choice C rationale

Metabolic acidosis is typically associated with conditions that cause the accumulation of acid in the body or the loss of bicarbonate, such as kidney disease, lactic acidosis, or certain poisonings. It is less likely in a patient who is nauseous and vomiting.

Choice D rationale

Respiratory acidosis is typically associated with conditions that cause an inability to remove enough carbon dioxide from the body, such as chronic obstructive pulmonary disease (COPD) or airway obstruction. It is less likely in a patient who is nauseous and vomiting.

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Correct Answer is D

Explanation

The correct answer is choiceD.

Choice A rationale:

Introducing a regular diet is not the immediate priority for a child with severe diarrhea.The focus should be on stabilizing the child’s condition before reintroducing regular foods.

Choice B rationale:

Maintaining fluid therapy is important, but it is part of the broader goal of managing fluid balance.It is not the first step in addressing severe diarrhea.

Choice C rationale:

Rehydration is crucial, but it falls under the broader category of assessing and managing fluid balance.Ensuring the child is properly hydrated is part of the overall assessment.

Choice D rationale:

Assessing fluid balance is the priority action. This involves evaluating the child’s hydration status, monitoring for signs of dehydration, and ensuring that fluid therapy is appropriately managed.This step is critical to prevent complications from severe diarrhea.

A. Place the client in a supine position. B. Withdraw the tube if the client gags during insertion. C. Instruct the client to place his chin to his chest and swallow. D. Measure the tube for insertion from the tip of the nose to the umbilicus. E. Measure the tube for insertion from the tip of the nose to the umbilicus.

Correct Answer is C

Explanation

Choice A rationale

Placing the client in a supine position is not recommended during nasogastric tube insertion. The client should be in an upright position, such as sitting up or in a high Fowler’s position, to facilitate the passage of the tube and reduce the risk of aspiration.

Choice B rationale

Withdrawing the tube if the client gags during insertion is not the correct action. Gagging is a common reaction during nasogastric tube insertion. The nurse should pause and allow the client to rest and swallow. The tube should only be withdrawn if the client is unable to breathe or is extremely distressed.

Choice C rationale

Instructing the client to place his chin to his chest and swallow can facilitate the passage of the tube through the esophagus. This position closes off the trachea and opens the esophagus, reducing the risk of the tube entering the trachea.

Choice D rationale

Measuring the tube for insertion from the tip of the nose to the umbilicus is not the correct method. The correct measurement is from the tip of the nose to the earlobe and then down to the xiphoid process of the sternum.

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A nurse is taking care of a patient who is nauseous and vomiting. Which of the following acid-base imbalances should the nurse identify the patient is at risk for?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse’s priority?

Correct Answer is D

Explanation

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is taking care of a patient who is nauseous and vomiting.
Which of the following acid-base imbalances should the nurse identify the patient is at risk for?