Correct Answer: C

Rationale: Metabolic alkalosis is a condition where the pH and the HCO3- are both elevated, indicating a loss of acids or a gain of bases in the body. This is not the case for this patient, as his HCO3- is within the normal range of 22 to 26 mEq/L. Respiratory acidosis is a condition where the pH and the PaCO2 are both low, indicating a retention of carbon dioxide in the lungs due to hypoventilation. This is not the case for this patient, as his pH is high and his PaCO2 is low. Respiratory alkalosis is a condition where the pH and the PaCO2 are both high, indicating a loss of carbon dioxide in the lungs due to hyperventilation. This is the case for this patient, as his pH is above the normal range of 7.35 to 7.45 and his PaCO2 is below the normal range of 35 to 45 mm Hg. This condition is uncompensated, as his HCO3- is within the normal range and has not changed to counteract the pH imbalance. Metabolic acidosis is a condition where the pH and the HCO3- are both low, indicating a gain of acids or a loss of bases in the body. This is not the case for this patient, as his pH is high and his HCO3- is within the normal range.

Correct Answer: A

Rationale: The client with an ileostomy is at risk for fluid volume deficit because an ileostomy is a surgical opening in the ileum, the last part of the small intestine, that allows the drainage of intestinal contents. This can result in a loss of fluids and electrolytes, especially sodium and potassium, which can lead to dehydration and hypovolemia. The client with cirrhosis is not at risk for fluid volume deficit, but rather fluid volume excess. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. This can lead to portal hypertension, which is an increase in the pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause ascites, which is the accumulation of fluid in the abdominal cavity, and edema, which is the swelling of the tissues due to fluid retention. The client with heart failure is not at risk for fluid volume deficit, but rather fluid volume excess. Heart failure is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to congestion of the blood vessels, which can cause pulmonary edema, which is the accumulation of fluid in the lungs, and peripheral edema, which is the swelling of the extremities due to fluid retention. The client with decreased renal function is not at risk for fluid volume deficit, but rather fluid volume excess. Decreased renal function is a condition where the kidneys are unable to filter the blood and remove excess fluids and wastes. This can lead to oliguria, which is a decrease in urine output, and anuria, which is the absence of urine output. This can cause fluid overload, which can affect the heart and the lungs.

Correct Answer: D

Rationale: 60 mL of urine in a 2-hour period is not very concerning for a nurse, as it is within the normal range of urine output. The average urine output for an adult is about 1 to 2 L per day, or 40 to 80 mL per hour. 720 mL of urine in a 24-hour period is slightly below the normal range, but not alarming. It may indicate mild dehydration or reduced fluid intake, but it is not a sign of fluid volume excess or kidney failure. 600 mL of urine in a 10-hour period is also within the normal range of urine output, and does not indicate any problem with fluid balance or renal function. 100 mL of urine in a 5-hour period is the most concerning for a nurse, as it indicates oliguria, or abnormally low urine output. Oliguria is defined as urine output less than 400 mL per day, or less than 20 mL per hour. It may be caused by acute or chronic kidney injury, urinary obstruction, shock, dehydration, or fluid volume excess. Oliguria can lead to fluid overload, electrolyte imbalance, acidosis, and uremia, and requires immediate medical attention.

Correct Answer: D

Rationale: Respiratory alkalosis is caused by hyperventilation, which lowers the carbon dioxide levels in the blood and raises the pH. This is not likely to occur in a client with a nasogastric tube on low suction. Metabolic acidosis is caused by an excess of acids or a loss of bases in the body, which lowers the pH. This can occur in conditions such as diabetic ketoacidosis, renal failure, or diarrhea. This is not likely to occur in a client with a nasogastric tube on low suction. Respiratory acidosis is caused by hypoventilation, which raises the carbon dioxide levels in the blood and lowers the pH. This can occur in conditions such as chronic obstructive pulmonary disease, asthma, or sedative overdose. This is not likely to occur in a client with a nasogastric tube on low suction. Metabolic alkalosis is caused by a loss of acids or an excess of bases in the body, which raises the pH. This can occur in conditions such as vomiting, gastric suction, or diuretic use. This is the most likely acid-base disorder to occur in a client with a nasogastric tube on low suction, as the tube removes gastric acid from the stomach.

Correct Answer: D

Rationale: This is incorrect because normal saline is not indicated for this client. Normal saline is a isotonic solution that does not alter the acid-base balance. The client has respiratory alkalosis, which is caused by hyperventilation and results in a high pH and a low PaCO2. This is incorrect because Allen's test is not relevant for this client. Allen's test is a test to assess the patency of the radial and ulnar arteries before performing an arterial blood gas (ABG) sampling or cannulation. The client already has ABG results, so there is no need to perform Allen's test. This is incorrect because increasing breathing would worsen the client's condition. Increasing breathing would cause the client to exhale more carbon dioxide, which would lower the PaCO2 and raise the pH even more. This would increase the severity of respiratory alkalosis. This is correct because slowing down breathing would help the client to correct the respiratory alkalosis. Slowing down breathing would allow the client to retain more carbon dioxide, which would increase the PaCO2 and lower the pH. This would bring the acid-base balance closer to normal.