A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon an assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the MOST common cause of which acid-base imbalance?
Respiratory Acidosis
Metabolic Alkalosis
Metabolic Acidosis
Respiratory Alkalosis
The Correct Answer is D
A. Respiratory Acidosis:
Explanation: Respiratory acidosis occurs when there is inadequate elimination of carbon dioxide, leading to an increase in PaCO2 and a decrease in blood pH. This is typically associated with conditions that impair ventilation.
B. Metabolic Alkalosis:
Explanation: Metabolic alkalosis is characterized by an elevated blood pH and bicarbonate (HCO3-) concentration. It is not directly caused by hyperventilation but is often associated with conditions such as excessive vomiting or excessive bicarbonate intake.
C. Metabolic Acidosis:
Explanation: Metabolic acidosis is characterized by a decrease in blood pH and bicarbonate concentration. It is not directly caused by hyperventilation but may result from conditions such as diabetic ketoacidosis or lactic acidosis.
D. Respiratory Alkalosis:
Explanation: Hyperventilation is the most common cause of respiratory alkalosis. During hyperventilation, there is an excessive loss of carbon dioxide (CO2) through rapid breathing, leading to a decrease in the partial pressure of carbon dioxide (PaCO2) in the blood. This results in an increase in blood pH, causing an alkalotic state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitoring the patient's breathing and reviewing the patient's arterial blood gases:
Rationale: While respiratory status is crucial in any patient assessment, arterial blood gases primarily evaluate respiratory function. Neutropenia directly affects the immune system, not respiratory function.
Appropriateness: Not directly related to assessing neutropenia.
B. Monitoring the patient's temperature and reviewing the patient's complete blood count with differential:
Rationale: Neutropenia can cause fever due to the increased risk of infection. Monitoring temperature and reviewing the complete blood count (CBC) with differential, specifically the neutrophil count, is essential in evaluating neutropenia and identifying potential infections.
Appropriateness: Correct. Monitoring temperature and reviewing CBC with differential are crucial in assessing neutropenia.
C. Monitoring the patient's blood pressure and reviewing the patient's hematocrit:
Rationale: Blood pressure assessment and hematocrit evaluation are essential aspects of general patient care but are not specific to neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
D. Monitoring the patient's heart rate and reviewing the patient's hemoglobin:
Rationale: Heart rate monitoring and hemoglobin assessment are crucial in various clinical situations but are not specific indicators of neutropenia.
Appropriateness: Not directly related to assessing neutropenia.
Correct Answer is D
Explanation
A. Respiratory acidosis:
This occurs when there is inadequate ventilation, leading to an accumulation of carbon dioxide (CO2) in the blood. In the context of a nasogastric tube attached to low suction, respiratory acidosis is not the primary concern. It is more associated with conditions like respiratory depression or lung diseases.
B. Metabolic acidosis:
Metabolic acidosis results from an excess of acid or a loss of bicarbonate. It is not the typical outcome of a nasogastric tube attached to low suction. Conditions like diarrhea or renal failure are more commonly associated with metabolic acidosis.
C. Respiratory alkalosis:
Respiratory alkalosis occurs when there is excessive loss of carbon dioxide from the body, often due to hyperventilation. This is not a typical consequence of a nasogastric tube attached to low suction.
D. Metabolic alkalosis:
Metabolic alkalosis is characterized by an excess of bicarbonate or a loss of acid. In the given context, with the nasogastric tube attached to low suction, there is a potential loss of gastric acid, contributing to metabolic alkalosis.
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