NUR 2243 Professional Nursing Skills I Exam 1 A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism?
- Increased rate and depth of respirations
- Increased urinary output
- Increased thirst and hunger
d. Increased release of acids from the kidneysANS: A
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 1 / 4
hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids A nurse assesses a client who is experiencing an acid-base imbalance.The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
- Cardiac rate and rhythm
- Skin and mucous membranes
- Musculoskeletal strength
d. Level of orientationANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the 2 / 4
acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.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?
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic acidosis
d. Metabolic alkalosisANS: D
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.A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
- Monitor daily hemoglobin and hematocrit values. 3 / 4
- Administer furosemide (Lasix) intravenously.
- Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.ANS: D
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 A nurse assesses a client who is admitted with an acid-base imbalance.The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?
- Assess clients rate, rhythm, and depth of respiration.
- Measure the clients pulse and blood pressure.
- Document the findings and continue to monitor.
- Notify the physician as soon as possible.ANS: A
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