ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 16 : Caring for Clients With Fluid, Electrolyte, and Acid? Base Imbalances Questions
Question 1 of 5
The nurse receives report that a client's $\mathrm{pH}$ level is 7.4. Which nursing action would be most appropriate?
Correct Answer: C
Rationale: The nurse realizes that a $\mathrm{pH}$ level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.
Question 2 of 5
The nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing respiratory acidosis. The client asks what is making the acidotic state. What does the nurse identify as the result of the disease process that causes the fall in $\mathrm{pH}$ ?
Correct Answer: D
Rationale: In clients with chronic respiratory acidosis, the client's lungs are not able to regulate carbonic acid levels. The increase in carbonic acid leads to acidosis. In COPD, the client is able to breathe in oxygen, and gas exchange can occur, but the lungs' ability to remove the carbon dioxide from the system is limited. Although individuals with COPD frequently have a history of smoking, ineffective cilia is not the cause of the acidosis.
Question 3 of 5
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?
Correct Answer: B
Rationale: Metabolic alkalosis results in increased plasma $\mathrm{pH}$ because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate- containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more $\mathrm{CO}_2$ than necessary.
Question 4 of 5
Upon shift report, the nurse states the following laboratory values: $\mathrm{pH}, 7.44 ; \mathrm{PCO}_2, 30 \mathrm{mmHg}$; and $\mathrm{HCO}_3, 21 \mathrm{mEq} / \mathrm{L}$ for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?
Correct Answer: A
Rationale: The question states that the client has a history of acid-base disturbance. The nurse would first note that the $\mathrm{pH}$ has returned to close to normal indicating compensation. The nurse then assess the $\mathrm{PCO}_2$ (normal: 35 to $45 \mathrm{~mm} \mathrm{Hg}$ ) and $\mathrm{HCO}_3$ (normal: 22 to $27 \mathrm{mEq} / \mathrm{L}$ ) levels. In a respiratory condition, the $\mathrm{pH}$ and the $\mathrm{PCO}_2$ move in opposite directions; thus, the $\mathrm{pH}$ rises and the $\mathrm{PCO}_2$ drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the $\mathrm{pH}$ and the bicarbonate move in the same direction; if the $\mathrm{pH}$ is low, the bicarbonate level will be low, also. In this client, the $\mathrm{pH}$ is at the high end of normal, indicating compensation and alkalosis. The $\mathrm{PCO}_2$ is low, indicating a respiratory condition (opposite direction of the $\mathrm{pH}$ ).
Question 5 of 5
The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage?
Correct Answer: C
Rationale: Foods high in sodium include processed meats, such as hot dogs and cold cuts; fast foods; frozen meals; cheeses; soups and juices; and salted snack foods to name a few.