An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain.
The patient is anxious, fearful, and hyperventilating.
What acid-base imbalance does the nurse anticipate the patient will develop?
Respiratory alkalosis.
Respiratory acidosis.
Metabolic alkalosis.
Metabolic acidosis.
The Correct Answer is A
Choice A rationale
Hyperventilation leads to a decrease in the amount of carbon dioxide (CO2) in the blood. This causes the pH of the blood to increase, resulting in respiratory alkalosis.
Choice B rationale
Respiratory acidosis is caused by a buildup of CO2 in the blood, typically due to hypoventilation (under-breathing). This is not consistent with the patient’s symptoms of hyperventilation.
Choice C rationale
Metabolic alkalosis is typically caused by a significant loss of acid from the body, such as from prolonged vomiting. This is not consistent with the patient’s symptoms.
Choice D rationale
Metabolic acidosis is typically caused by an increase in acid production within the body or a loss of bicarbonate from the body, such as in diabetic ketoacidosis or kidney disease. This is not consistent with the patient’s symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Given the client’s risk factors of poor wound healing, decreased bone density, and increased capillary fragility, the most appropriate outcome statement to include in the plan of care is that the client implements measures to prevent injury. This includes avoiding falls, using caution with sharp objects to prevent cuts, and taking steps to protect the bones.
Choice B rationale
While it is important for the client to understand their disease and ways to control it, this is not the most appropriate outcome statement given the client’s specific risk factors.
Choice C rationale
Improving body image may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Choice D rationale
Experiencing a normal fluid balance may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Correct Answer is B
Explanation
Choice A rationale
A blood glucose level of 90 mg/dL (5 mmol/L) is within the normal range and would not need to be reported to the surgeon.
Choice B rationale
A serum creatinine level of 5 mg/dL (442 µmol/L) is significantly elevated, indicating impaired kidney function. This is a critical lab value that should be reported to the surgeon immediately, as it could impact the patient’s ability to safely undergo surgery and recover postoperatively.
Choice C rationale
A hemoglobin level of 13 g/dL (130 g/L) is within the normal range and would not need to be reported to the surgeon.
Choice D rationale
A potassium level of 4 mEq/L (4 mmol/L) is within the normal range and would not need to be reported to the surgeon.
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