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The nurse is caring for a client with metabolic acidosis.
Which goals are
appropriate for this client? Select all
that apply.
A) The client will maintain a respiratory rate of 30 or more.
B) The client will describe preventative measure for the
underlying chronic illness.
C) The client will maintain baseline cardiac rhythm.
D) The client will remain in a pH range from 7.25 to 7.35.
E) The client will take potassium supplements to increase
potassium levels. - ANSWER-Answer: B, C
Explanation: Planning for the client with metabolic acidosis
involves identification and treatment of the underlying cause
and restoration and maintenance of acid-base balance. The
client should be able to describe preventative measures for the
underlying chronic illness that caused the metabolic acidosis
to occur and maintain the baseline cardiac rhythm. The pH
should be maintained between 7.35 and 7.45. The client's
respiratory rate should be within normal range for age and
condition. Taking a potassium supplement may cause
,hyperkalemia, which decreases cardiac output and worsens
metabolic acidosis.
The nurse is caring for a client admitted with renal failure and
metabolic acidosis. Which clinical manifestation would indicate
to the nurse that planned interventions to relieve the metabolic
acidosis have been effective?
A) Decreased respiratory
depth
B)
Palpitations
C) Increased deep tendon
reflexes
D) Respiratory rate of 38 - ANSWER-
Answer: A
Explanation: The client with metabolic acidosis will have an
increased respiratory rate and depth, called Kussmaul
respirations. Signs that care has been effective would include a
decrease in the rate and depth of respirations. An increased
respiratory rate, as indicated by a respiratory rate of 38, would
indicate continued metabolic acidosis. Increased deep tendon
reflexes and palpitations are not associated with metabolic
acidosis.
The nurse is caring for the client experiencing hypovolemic
shock and metabolic
,acidosis. Which therapies would the nurse question if
planned for this client?
Select all that
apply.
A) Monitor weight on admission and
discharge.
B) Monitor ECG for conduction
problems.
C) Limit the intake of
fluids.
D) Administer sodium
bicarbonate.
E) Keep the bed in the locked and low position. - ANSWER-
Answer: A, C
Explanation: The treatment for hypovolemic shock would
include the administration of fluids, not limiting fluids. Patients
being treated for hypovolemia and metabolic acidosis will
require daily weights, not a weight on admission and then
discharge. Administering sodium bicarbonate and monitoring
ECGs are appropriate for the client with metabolic acidosis.
The client recovering from hypovolemic shock and metabolic
acidosis is at risk for injury, so the bed should be kept in the
locked and low position.
A client with metabolic acidosis has been admitted to
the unit from the
, emergency department (ED). The client is experiencing
confusion and
weakness. Which nursing intervention is the priority
for this client?
A) Placing the client in a high-Fowler
position
B) Protecting the client
from injury
C) Administering sodium
bicarbonate
D) Providing the client with appropriate skin care -
ANSWER-Answer: B
Explanation: The client with metabolic acidosis may have
symptoms of drowsiness, lethargy, confusion, and weakness.
A priority of care would be preventing injury to the client.
Medication administration is a physician order. Skin care would
not be a priority on admission. The high-Fowler position would
not be the safest position for the confused client.
The nurse is preparing to teach a client with type 1 diabetes
mellitus on the mechanism behind the development of
ketoacidosis. List the order in which the nurse should provide
this information.
1. Production of lactate and
hydrogen ions