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.
Respiratory acidosis.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.
Choice B rationale
Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.
Choice C rationale
Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.
Choice D rationale
Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.
Correct Answer is A
Explanation
Choice A rationale
Performing hand hygiene frequently and consistently is the most effective way to prevent the spread of pathogens during patient care. Hand hygiene is the single most important measure to reduce the transmission of harmful germs and prevent health care-associated infections.
Choice B rationale
Properly disposing of contaminated equipment is important in preventing the spread of pathogens, but it is not the most effective measure. While it is crucial to handle and dispose of contaminated equipment properly, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice C rationale
Discarding used syringes in appropriate containers is a standard safety measure in healthcare settings, but it is not the most effective way to prevent the spread of pathogens during patient care. While it is important for preventing needlestick injuries and the spread of bloodborne pathogens, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice D rationale
Changing soiled linens daily for patients with draining wounds is a part of standard wound care and infection control, but it is not the most effective way to prevent the spread of pathogens during patient care. Hand hygiene remains the most effective measure in preventing the spread of pathogens.
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