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Concepts of Acid–Base Balance Ignatavicius: Medical-Surgical Nursing, 10th Edition

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Concepts Of Acid–Base Balance Ignatavicius

Concepts of Acid–Base Balance Ignatavicius: Medical-Surgical Nursing, 10th EditionMULTIPLE CHOICE 1. A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 ...

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Chapter 14: Concepts of Acid–Base Balance Ignatavicius: Medical-Surgical
Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance. The
client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18
mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client’s
compensatory mechanisms?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys

ANS: 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 signs and
symptoms of hyperglycemia but are not compensatory mechanisms for acid–base imbalances. The
kidneys do not release acids.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances,
Acidosis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial blood
gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19 mmol/L).
Which assessment would the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation

ANS: 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. The nurse responds by performing a thorough cardiovascular assessment.
Changes will occur in the integumentary system, musculoskeletal system, and neurologic system, but
assessing for the cardiovascular complications comes first.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalance,
Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse assesses a client who is prescribed furosemide for hypertension. For which acid–base
imbalance does the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

A++

,ANS: D
Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions,
leading to excess acid loss through the renal system. This situation is an actual acid deficit.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalance,
Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action would
the nurse take?
a. Monitor daily hemoglobin and hematocrit values.
b. Administer furosemide intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.

ANS: D
The most important nursing care for a client who is experiencing moderate metabolic alkalosis is
providing client safety. Client’s with metabolic alkalosis have muscle weakness and are at risk for
falling. The other nursing interventions are not appropriate for metabolic alkalosis.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalance, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base imbalance.
For which manifestation of this acid–base imbalance would the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvostek sign

ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic acidosis
through underproduction of bicarbonate ions. Signs and symptoms of acidosis include lethargy and
Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign are signs and symptoms of
the electrolyte imbalances that accompany alkalosis.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Acid-base imbalances,
Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse assesses a client who is admitted with an acid–base imbalance. The client’s arterial blood
gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L).
The most recent blood gasses show a drop in the pH. What action does the nurse take next?
a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the primary health care provider.

ANS: A

A++

, Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle
weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to
hyperkalemia), but these would best be assessed with cardiac monitoring. Findings would be
documented, but simply continuing to monitor is not sufficient. Before notifying the primary care
provider, the nurse must have more data to report.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalances,
Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm
Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does the nurse
correlate with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman

ANS: B
Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate,
suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide
are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory
acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that
this is an acute respiratory problem rather than a chronic problem, because no renal compensation
has occurred. The client who would have these ABG values is the one with the new onset of airway
obstruction.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Acid-base imbalances,
Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22
mEq/L (22 mmol/L). What action would the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the client’s nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

ANS: A
This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client can
breathe again normally, so oxygen administration will rapidly increase the PaO2.
Rebreathing carbon dioxide with a paper bag would make the acidosis worse. Bicarbonate is only
indicated with extremely low pH and serum bicarbonate levels. Glucose and insulin are administered
to decrease the high potassium levels associated with acidosis, but this situation should reverse itself
with oxygen and breathing.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Acid-base imbalance,
Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

A++

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Exam (elaborations)

Concepts of Acid–Base Balance Ignatavicius: Medical-Surgical Nursing, 10th Edition

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