CH 42 Acid-Base Regulation -sherpath- week 5

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Questions and Answers

Which hypotheses would the nurse consider when handed over a patient with an acid-base imbalance who has Kussmaul respirations and is reported to be hypotensive and dysrhythmic?

  • Impaired Gas Exchange
  • Hyperventilation
  • Excess acid production (correct)
  • Excess serum bicarbonate

Which additional cues would the nurse expect when caring for a patient with Acute Confusion associated with respiratory alkalosis?

  • Muscle cramping (correct)
  • Restlessness (correct)
  • Tachypnea (correct)
  • Paresthesia

Match each hypothesis with the acid-base imbalance.

Impaired Gas Exchange = Respiratory acidosis Hyperventilation = Respiratory alkalosis Excess acid production = Metabolic acidosis Excess serum bicarbonate = Metabolic alkalosis

The nurse is caring for a patient with dyspnea and impaired gas exchange secondary to chest injury causing respiratory acidosis. Which evaluation would the nurse include in the plan of care to specifically monitor a goal of returning blood pressure to baseline or within normal limits (WNL) within 24 hours of admission?

<p>Vital signs (B)</p> Signup and view all the answers

Which solutions are appropriate for a nurse to include in the plan of care for a diabetic patient with metabolic acidosis?

<p>Decrease blood sugar (A), Replace fluid loss (C), Correct electrolyte imbalances (D)</p> Signup and view all the answers

An older adult patient with a history of tobacco use reports fatigue, decreased energy, and difficulty breathing. The hypothesis includes Impaired Gas Exchange with respiratory acidosis. Which goal statement specific for fatigue would the nurse include in the plan of care?

<p>Patient will verbalize feelings of increased energy within 24 hours of admission. (A)</p> Signup and view all the answers

Which explanation would a nurse include in the response to a patient diagnosed with high blood pressure who asks, “Why do I have to monitor my salt intake?”

<p>“Sodium has an effect on your blood pressure. Since your blood pressure is high, you should decrease your salt intake.” (B)</p> Signup and view all the answers

Which electrolyte supplement is most important for the nurse to include in a teaching session for a patient who is recovering from a broken bone?

<p>Calcium (C)</p> Signup and view all the answers

Which supplements would a nurse include when asked by patient with osteoporosis, “Is there anything I can take over-the-counter to manage my condition?”

<p>Calcium (B), Magnesium (C)</p> Signup and view all the answers

Which primary functions would the nurse include when teaching the patient about electrolytes within the body?

<p>Transmitting nerve impulses (A), Regulating acid-base balance (B), Altering the action potential of nerve fibers (C), Maintaining fluid osmolality (D)</p> Signup and view all the answers

A patient has developed a clot in a coronary artery, and the heart muscle cells did not make enough adenosine triphosphate (ATP). Which explanation would the nurse give a nursing student about the effect of poor ATP supply on electrolyte movement?

<p>Active transport will be impaired, so the sodium-potassium pumps will not work normally. (C)</p> Signup and view all the answers

Which statement regarding electrolyte movement from one compartment to another would the nursing student include in a class presentation?

<p>“The movement of electrolytes is necessary to preserve their distribution.” (D)</p> Signup and view all the answers

Which statements regarding the sodium-potassium pump are true?

<p>Adenosine triphosphate (ATP) is required for the sodium-potassium pump to move sodium and potassium ions. (A), This pump moves sodium out of the cell and potassium into the cell. (B), This pump moves three sodium ions for every two potassium ions. (D)</p> Signup and view all the answers

The nursing student is presenting information about the movement of electrolytes to fellow classmates. Which process would the nursing student describe as the movement of electrolytes across a membrane using a carrier?

<p>Facilitated diffusion (B)</p> Signup and view all the answers

The nurse is educating a patient regarding the normal levels of potassium within the blood. Which response by the patient indicates a correct understanding of the information presented?

<p>“The normal range for potassium is 3.5 to 5 mEq/L.” (B)</p> Signup and view all the answers

The nurse is providing care to a patient with decreased levels of serum potassium caused by excessive hormone action that shifts potassium into cells. Which hormone would the nurse expect to be elevated in the laboratory report?

<p>Insulin (A)</p> Signup and view all the answers

Which data would the nurse report to the primary health care provider as abnormal when monitoring serum electrolyte levels for a patient admitted with dehydration?

<p>Serum Na+ of 150 mEq/L (A), Serum K+ of 5.2 mEq/L (B), Serum PO43- of 2.9 mEq/L (D)</p> Signup and view all the answers

Which factors would a nurse assess for when admitting a patient with an alteration in total body water (TBW)?

<p>Age (A), Gender (B), Body weight (C), Overall health (D)</p> Signup and view all the answers

An intravascular fluid sample is to be collected from a patient. Based on the location of this type of fluid, the nurse would inform the patient that the sample will come from which source?

<p>Blood (B)</p> Signup and view all the answers

Which information regarding solutes would a nurse include when preparing a continuing education class on body fluid components?

<p>Colloids do not fully dissolve in a solvent. (B)</p> Signup and view all the answers

Which type of problem would a nurse expect when caring for a patient with a blood disease that has significantly reduced the number of red blood cells?

<p>Oxygenation (A)</p> Signup and view all the answers

Which type of blood would a nurse anticipate transfusing to a patient who tests positive for Rhesus (Rh) factor and no ABO antigen in the blood?

<p>Type O+ blood (C)</p> Signup and view all the answers

Which components of donated blood would a nurse at a community blood drive explain can be separated for individual use?

<p>Red blood cells (A), Plasma (B), Albumin (C), Cryoprecipitate (D)</p> Signup and view all the answers

Which effect on oncotic pressure would a nurse expect when caring for a patient with a kidney disorder causing low levels of plasma protein?

<p>Decreased oncotic pressure, which decreases the amount of water shifting into the blood. (B)</p> Signup and view all the answers

Which information would a student nurse include when explaining the process of filtration to another student?

<p>Filtration is the movement of water and solutes from an area of higher net pressure to lower net pressure. (A)</p> Signup and view all the answers

Which rationale would the nurse associate with thirst in a frail, confused older patient with dehydration secondary to severe vomiting who is continuously calling for water even though he is nauseated?

<p>Increased plasma osmolality and decreased plasma volume (B)</p> Signup and view all the answers

Which patient factors controlling hydrostatic pressure would a nurse consider when caring for a patient with heart disease?

<p>The strength of the heart muscle contraction (A), Heart rate (B), Blood pressure (C)</p> Signup and view all the answers

Which alteration in body water homeostasis would a nurse expect in a patient whose posterior pituitary gland no longer releases antidiuretic hormone (ADH)?

<p>Body water will be lost in large volumes. (B)</p> Signup and view all the answers

Which information regarding the renin-angiotensin-aldosterone system would be included by a student nurse making flashcards for an exam focusing on body fluid homeostasis?

<p>Renin converts angiotensinogen into angiotensin I. (A), The renin-angiotensin-aldosterone system regulates fluid balance through vasoconstriction and excretion of sodium and water. (D)</p> Signup and view all the answers

Which information would a nurse include when teaching about Rhesus (Rh) factor?

<p>If Rh antibodies have developed, a life-threatening reaction can occur. (B), Rh antibodies can develop during pregnancy. (D)</p> Signup and view all the answers

Which statements are important for a nurse to know about the filtration process?

<p>It is the movement of water and solutes together. (A), Arterial blood pressure affects hydrostatic pressure. (C)</p> Signup and view all the answers

Which processes would a nurse include when teaching about the regulation of blood pressure and fluid balance by the renin-angiotensin-aldosterone system?

<p>Vasoconstriction (A), Release of aldosterone (B), Reabsorption of sodium (C)</p> Signup and view all the answers

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