ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 12 Questions
Question 1 of 5
A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?
Correct Answer: D
Rationale: Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin, resulting in metabolic alkalosis.
Question 2 of 5
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.5, PaCO2 30 mm Hg, PaO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism?
Correct Answer: A
Rationale: This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.
Question 3 of 5
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaCO2 30 mm Hg, PaO2 80 mm Hg, and HCO3- 18 mEq/L. Which assessment should the nurse perform first?
Correct Answer: A
Rationale: Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As acidosis worsens, the heart rate increases and electrocardiographic changes may be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now.
Question 4 of 5
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestations of this acid-base imbalance should the nurse assess?
Correct Answer: B
Rationale: The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek's sign are manifestations of the electrolyte imbalances that accompany alkalosis.
Question 5 of 5
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
Correct Answer: D
Rationale: The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.