1. The nurse is caring for a client with a nasogastric tube that is attached to low suction.
The nurse monitors the client for manifestations of which disorder that the client is at risk
for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis: B. Metabolic alkalosis
Rationale:
>Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess
of base (bicarbonate) that results from the accumulation of base or from a loss of acid
without a comparable loss of base in the body fluids.
>This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, exces- sive
bicarbonate intake, the massive transfusion of whole blood, and hyperaldos- teronism.
>Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a
result of the loss of hydrochloric acid
2. On review of the clients' medical records, the nurse determines that which client is at
risk for
fluid volume excess?
A. The client taking diuretics who has tenting of the skin
B. The client with an ileostomy from a recent abdominal surgery
C. The client who requires intermittent gastrointestinal suctioning
D. The client with kidney disease and a 12-year history of diabetes mellitus: D. The client
with kidney disease and a 12-year history of diabetes mellitus
3. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5
mmol/L)?
A. The client with colitis
B. The client with Cushing's syndrome
, C. The client who has been overusing laxatives
D. The client who has sustained a traumatic burn: D. The client who has sus- tained a
traumatic burn
Rationale:
>The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium
level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia.
>Clients who experience cellular shifting of potassium in the early stages of massive cell
destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are a
risk for hyperkalemia.
>The client with Cushing's syndrome or colitis and the client who has been overusing laxative
are at risk for hypokalemia
4. A client with a 3-day history of nausea and vomiting presents to the emer- gency
department.
The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The
electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per
minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to
note
which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3-
D. An increased pH and an increased HCO3-: D. An increased pH and an in- creased
HCO3-
Rationale:
>Clients experiencing nausea and vomiting would most likely present with metabolic alkalos
resulting from loss of gastric acid, thus causing the pH and HCO3, to increase.
>Symptoms experienced by the client would include a decrease in the respiratory
The nurse monitors the client for manifestations of which disorder that the client is at risk
for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis: B. Metabolic alkalosis
Rationale:
>Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess
of base (bicarbonate) that results from the accumulation of base or from a loss of acid
without a comparable loss of base in the body fluids.
>This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, exces- sive
bicarbonate intake, the massive transfusion of whole blood, and hyperaldos- teronism.
>Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a
result of the loss of hydrochloric acid
2. On review of the clients' medical records, the nurse determines that which client is at
risk for
fluid volume excess?
A. The client taking diuretics who has tenting of the skin
B. The client with an ileostomy from a recent abdominal surgery
C. The client who requires intermittent gastrointestinal suctioning
D. The client with kidney disease and a 12-year history of diabetes mellitus: D. The client
with kidney disease and a 12-year history of diabetes mellitus
3. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5
mmol/L)?
A. The client with colitis
B. The client with Cushing's syndrome
, C. The client who has been overusing laxatives
D. The client who has sustained a traumatic burn: D. The client who has sus- tained a
traumatic burn
Rationale:
>The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium
level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia.
>Clients who experience cellular shifting of potassium in the early stages of massive cell
destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are a
risk for hyperkalemia.
>The client with Cushing's syndrome or colitis and the client who has been overusing laxative
are at risk for hypokalemia
4. A client with a 3-day history of nausea and vomiting presents to the emer- gency
department.
The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The
electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per
minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to
note
which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3-
D. An increased pH and an increased HCO3-: D. An increased pH and an in- creased
HCO3-
Rationale:
>Clients experiencing nausea and vomiting would most likely present with metabolic alkalos
resulting from loss of gastric acid, thus causing the pH and HCO3, to increase.
>Symptoms experienced by the client would include a decrease in the respiratory
