The nurse identifies which client to be at risk for developing metabolic alkalosis? The client who:
has been vomiting for three days.
has had diarrhea for the past 24 hours.
has overdosed on heroin.
is admitted with an asthma exacerbation.
The Correct Answer is A
A. Vomiting results in loss of hydrochloric acid (HCl) from the stomach, leading to a loss of chloride ions (Cl-) and hydrogen ions (H+) from the body. This loss of hydrogen ions can result in an accumulation of bicarbonate ions (HCO3-) relative to hydrogen ions, leading to metabolic alkalosis. Therefore, this client is at risk for developing metabolic alkalosis due to prolonged vomiting.
B. Client who has had diarrhea for the past 24 hours: Diarrhea leads to loss of bicarbonate ions (HCO3-) from the body along with fluid and electrolytes. However, metabolic alkalosis is less likely to occur with diarrhea alone because the loss of bicarbonate ions is usually balanced by the loss of chloride ions (Cl-) and hydrogen ions (H+). Therefore, while diarrhea can lead to metabolic acidosis in some cases, it is less likely to cause metabolic alkalosis.
C. Client who has overdosed on heroin: Heroin overdose is not directly associated with metabolic alkalosis. In the context of heroin overdose, respiratory depression leading to respiratory acidosis is a more immediate concern. Therefore, this client is not at risk for developing metabolic alkalosis due to heroin overdose.
D. Client who is admitted with an asthma exacerbation: Asthma exacerbation can lead to respiratory alkalosis due to hyperventilation and excessive elimination of carbon dioxide (CO2) from the body. However, metabolic alkalosis is not a typical consequence of asthma exacerbation alone. Therefore, while this client may experience respiratory alkalosis, they are not at risk for developing metabolic alkalosis solely due to asthma exacerbation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.
Correct Answer is B
Explanation
B. A PICC line is a long, flexible catheter inserted into a peripheral vein, typically in the upper arm, and advanced until the tip lies in the superior vena cava or the cavoatrial junction. PICC lines are suitable for long-term venous access and are often used for administering medications, including antibiotics, over several weeks or months. They offer stable and reliable access, reducing the need for frequent venipunctures.
A. Butterfly needles are typically used for short-term venous access, such as for blood draws or administering medications that do not require long-term therapy. They are not suitable for prolonged use or for administering medications over several weeks, as they are not designed for secure and stable access over an extended period.
C. A peripheral IV-lock, also known as a saline lock or heplock, is a short catheter inserted into a peripheral vein and then capped off for intermittent use. While peripheral IV-locks are suitable for short-term venous access, they are not ideal for prolonged therapy lasting several weeks. Additionally, they may not provide the necessary stability and reliability for administering IV antibiotics over an extended period.
D. A small gauge peripheral angiocath refers to a short catheter inserted into a peripheral vein for intravenous access. While a larger gauge catheter, such as a 16-gauge, may allow for faster infusion rates and is suitable for certain situations requiring rapid fluid administration, it may not be the most appropriate choice for long-term IV antibiotic therapy. The choice of gauge depends on factors such as the client's vein size, the viscosity of the medication, and the duration of therapy.
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