Acid-Base
Which priority nursing intervention would the nurse implement for a client on diuretic therapy who has developed metabolic alkalosis?
Fall prevention measures
Monitoring electrolytes
Administering antiemetics
Adjusting the diuretic therapy
Fall prevention measures.
A client with alkalosis has hypotension and muscle weakness, which increases the risk for injury due to falls; therefore, to prevent injury, the priority nursing care is to prevent falls. Monitoring electrolytes daily until they return to normal is not the priority nursing care. Antiemetics are prescribed for vomiting and are given low priority. Once the client is protected from the risk for injury, diuretic therapy is adjusted.
When will the nurse monitor for a potential hypoglycemic reaction after administering daily regular insulin to a client with type 1 diabetes at 8 AM?
A. At breakfast
B. Before lunch
C. Before dinner
D. In the early afternoon
B. Before lunch
Rationale: Regular insulin is short acting and peaks in 2 to 4 hours, which in this case will be at or before lunch. Breakfast is too soon; regular insulin peaks in 2 to 4 hours. Before dinner is too late; regular insulin peaks in 2 to 4 hours. The early afternoon is too late; regular insulin peaks in 2 to 4 hours.
Which effect of sodium bicarbonate is the nurse trying to prevent when teaching a client about the dangers of using sodium bicarbonate regularly?
Gastric distention
Metabolic alkalosis
Chronic constipation
Cardiac dysrhythmias
Metabolic alkalosis
Prolonged use of sodium bicarbonate may cause systemic alkalosis, as well as retention of sodium and water. Gastric distention is not an effect of sodium bicarbonate. Chronic constipation is not an effect of sodium bicarbonate. Cardiac dysrhythmias are not an effect of sodium bicarbonate.
When caring for a client who has hypokalemia, which electrocardiogram change will the nurse expect to observe?
A. Inverted P waves
B. Flattened T waves
C. Absence of U waves
D. Elevated ST segment
B. Flattened T Waves
A flattened T wave is associated with hypokalemia. A depressed T wave indicates a problem with ventricular repolarization, a process involved in muscle contraction. Adequate potassium levels are needed for efficient muscle contraction. P waves may peak in hypokalemia. In hypokalemia, U waves appear. ST segment is depressed in hypokalemia.
Which laboratory results support the nurse's suspicion that a client diagnosed with type 1 diabetes is experiencing ketoacidosis?
Blood glucose of 40 mg/100 mL (2.2 mmol/L), blood pH of 7.37
Blood glucose of 130 mg/100 mL (7.2 mmol/L), blood pH of 7.35
Blood glucose of 650 mg/100 mL (36.1 mmol/L), blood pH of 7.42
Blood glucose of 300 mg/100 mL (16.7 mmol/L), blood pH of 7.20
Blood glucose of 300 mg/100 mL (16.7 mmol/L), blood pH of 7.20
The blood glucose level of 300 mg/100 mL (16.7 mmol/L) is greater than the expected range of individuals with type 1 diabetes, indicating hyperglycemia. The normal serum pH is 7.35 to 7.45; therefore, 7.20 indicates acidosis. The blood glucose level of 40 mg/100 mL (2.2 mmol/L) is less than the expected range for all individuals, indicating hypoglycemia; the serum pH of 7.37 is within the expected range for pH. The blood glucose level of 130 mg/100 mL (7.2 mmol/L) is within the expected range for individuals with type 1 diabetes, and the pH of 7.35 is within the expected range for pH. The blood glucose level of 650 mg/100 mL (36.1 mmol/L) indicates hyperglycemia, but the serum pH is within the expected range for pH.
Which rationale explains why intravenous (IV) potassium is prescribed in addition to regular insulin for clients in diabetic ketosis?
Potassium loss occurs rapidly from diaphoresis present during coma.
Potassium is carried with glucose to the kidneys to be excreted in the urine in increased amounts.
Potassium is quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose.
Serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment.
Serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment.
Insulin stimulates cellular uptake of glucose and stimulates the sodium/potassium pump, leading to the influx of potassium into cells. The resulting hypokalemia is offset by parenteral administration of potassium. Potassium is not lost from the body by profuse diaphoresis. Potassium moves from the extracellular to the intracellular compartment rather than being excreted in the urine. Anabolic reactions are stimulated by insulin and glucose administration; potassium is drawn into the intracellular compartment, necessitating a replenishment of extracellular potassium.
Which response would a nurse give to a client diagnosed with type 1 diabetes who states "I hate shots. Why can’t I take the insulin in tablet form?"
A. "Your diabetic condition is too serious for oral insulin."
B. "Insulin is poorly absorbed orally, so it is not available in a tablet."
C. "Insulin by mouth causes a high incidence of allergic and adverse reactions."
D. "Once your diabetes is controlled, your primary health care provider might consider oral insulin."
B. "Insulin is poorly absorbed orally, so it is not avaliable in a tablet."
Rationale: The chemical structure of insulin is altered by gastric secretions, rendering it ineffective. There is no such thing as oral insulin; this comment about the seriousness of the diabetic condition may increase anxiety. There are no data to support the statement regarding allergic or adverse reactions, and insulin is given parenterally, not orally. Insulin is not absorbed but is destroyed by gastric secretions; there is no insulin that is effective if taken by mouth.
Which medication can help prevent a life-threatening crisis when adminstered immediately to a client with severe hyperkalemia who develops acidosis?
50% dextrose
Furosemide
Sodium bicarbonate
Epinephrine
Sodium Bicarbonate.
Sodium bicarbonate decreases the potassium level if acidosis is present. Infusion of sodium bicarbonate moves the pH toward alkalinity and thereby increases cellular uptake of potassium. Administration of glucose and insulin can promote movement of potassium into cells, but glucose alone doesn’t have this effect. Loop diuretics such as furosemide are useful for mild to moderate hyperkalemia, but when the severity of the condition has progressed to a stage of acidosis, other medications are indicated. Epinephrine is an emergency medication, but it is not indicated for this purpose.
Which assessment finding in a client signifies a mild form of hypocalcemia?
A. Seizures
B. Hand spasms
C. Severe muscle cramps
D. Numbness around the mouth
D. Numbness around the mouth
A numbness or tingling sensation around the mouth or in the hands and feet indicates mild to moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.
Which unique response is associated with diabetic ketoacidosis (DKA) that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
A. Fluid loss
B. Glycosuria
C. Kussmaul respirations
D. Increased blood glucose level
C. Kussmaul respirations
Rationale: Kussmaul respirations occur in diabetic ketoacidosis (DKA) as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.
When the nurse is reviewing a client’s arterial blood gas results, which finding would the nurse identify as being consistent with respiratory alkalosis?
A decreased pH, elevated PCO 2
An elevated pH, decreased PCO 2
A decreased pH, decreased PCO 2
An elevated pH, elevated partial pressure of carbon dioxide (PCO 2)
An elevated pH, decreased PCO 2
In respiratory alkalosis, the pH level is elevated because of loss of hydrogen ions; the PCO 2 level is low because carbon dioxide is lost through hyperventilation. A decreased pH and elevated PCO 2 are respiratory acidosis. A decreased pH and decreased PCO 2 are metabolic acidosis with some compensation. An elevated pH and elevated PCO 2 are partially compensated metabolic alkalosis.
Which insulin would the nurse conclude has the fastest onset of action?
A. NPH insulin
B. Insulin lispro
C. Regular insulin
D. Insulin glargine
B. Insulin lispro
Insulin lispro has an onset of 0.25 hours, a peak action of 0.5 to 1.5 hours, and a duration of 3 to 4 hours. Neutral protamine Hagedorn (NPH) or intermediate-acting insulin has an onset of 1.5 hours, a peak action of 4 to 12 hours, and a duration of 18 to 24 hours. Regular insulin has an onset of 0.5 hours, a peak action of 1 to 5 hours, and a duration of 6 to 10 hours. Insulin glargine has an onset of 1 to 1.5 hours, no peak action, and a duration of 20 to 24 hours.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco 2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Respiratory Acidosis
The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO 2, and the acceptable range of arterial Pco 2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO 3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.
Which statement about administration of IV potassium would a nurse make to a client with a diagnosis of hypokalemia?
Oliguria is an indication for withholding IV potassium.
Rapid infusion of potassium prevents burning at the IV site.
Clients with severe deficits should be given IV push potassium.
Average IV dosage of potassium should not exceed 60 mEq in 1 hour.
A. Oliguria is an indication for withholding IV potassium.
Potassium chloride should not be given unless renal flow is adequate; otherwise, the potassium chloride will accumulate in the body, causing hyperkalemia. Rapid infusion may cause severe pain at the infusion site and precipitate cardiac arrest. Potassium chloride must be well diluted or it will precipitate cardiac arrest. A dose of 60 mEq per hour of potassium chloride is too high.
Which common cause of diabetic ketoacidosis would the nurse consider when caring for a postoperative client with diabetes?
A. Emotional stress
B. Presence of infection
C. Increased insulin dose
D. Inadequate food intake
B. Presence of infection
Rationale: Infection increases the body's metabolic rate, and insulin is not available for increased demands. Although emotional stress will affect glucose levels, diabetic ketoacidosis will rarely result. Increased insulin dose will lead to hypoglycemia if diet is not increased as well. Inadequate food intake will result in hypoglycemia.
An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus?
Ketones
Glucose
Lactic acid
Glutamic acid
Ketones
The ketones produced excessively in diabetes are a byproduct of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis. Glucose does not change the pH. Lactic acid is produced as a result of muscle contraction; it is not unique to diabetes. Glutamic acid is a product of protein metabolism.
Which action would be taken by the nurse caring for a client with type 1 diabetes mellitus who has a finger-stick glucose level of 258 mg/dL (14.3 mmol/L) at bedtime and a prescription for sliding-scale regular insulin?
A. Call the health care provider.
B. Encourage intake of fluids.
C. Administer the insulin as prescribed.
D. Give the client 4 ounces of orange juice.
C. Administer the insulin as prescribed
Rationale: A value of 258 mg/dL (14.3 mmol/L) is above the expected range of 70 to 100 mg/dL (3.6–5.6 mmol/L); the nurse would administer the regular insulin as prescribed. Calling the health care provider is unnecessary; a prescription for insulin exists and should be implemented. Encouraging the intake of fluids is insufficient to lower a glucose level this high. Giving the client orange juice is contraindicated because this will increase the glucose level further. Orange juice, a complex carbohydrate, and a protein should be given if the glucose level is too low.
Which diagnosis is suspected by the nurse when the laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 45 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L)?
Hypocapnia
Hyperkalemia
Metabolic alkalosis
Respiratory acidosis
Metabolic Alkalosis
Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 45 mm Hg is within the expected value of 35 mm Hg to 45 mm Hg; no hypocapnia is present. The client’s serum potassium level is within the expected level of 3.5 mEq/L to 5 mEq/L (3.5–5 mmol/L). With respiratory acidosis, the pH will be less than 7.35 and the Pco 2 will be elevated.
Which findings are consistent with hypercalcemia after prolonged immobility? Select all that apply. One, some, or all responses may be correct.
A. Bone pain
B. Convulsions
C. Muscle spasms
D. Tingling of extremities
E. Depressed deep tendon reflexes
A. Bone Pain & D. Tingling of extremities
Increased serum calcium comes from bone demineralization, which results in bone pain. Depressed or absent deep tendon reflexes are associated with hypercalcemia. The body’s excitable tissues are affected most (e.g., nerves, muscles, heart, intestinal smooth muscles). Convulsions are not a sign of hypercalcemia; convulsions can occur with hypocalcemia, hypernatremia, and hyponatremia. Muscle spasms are not a sign of hypercalcemia; muscle spasms can occur with hypocalcemia, hyponatremia, and hypokalemia. Tingling of extremities is not a sign of hypercalcemia; paresthesias are associated with hypocalcemia and hyperkalemia.
An adolescent with type 1 diabetes mellitus is admitted to the intensive care unit in ketoacidosis with a blood glucose level of 170 mg/dL (9.4 mmol/L). A continuous insulin infusion is started. Which adverse reaction to the infusion is most important for the nurse to monitor?
A. Hypokalemia
B. Hypovolemia
C. Hypernatremia
D. Hypercalcemia
A. Hypokalemia
Rationale: Insulin moves potassium into the cells along with glucose, thus lowering the serum potassium level. Insulin does not lead to a reduced blood volume. Insulin does not directly alter the sodium levels. Insulin does not affect the calcium levels.
Which manifestation would the nurse include when teaching a client about ketoacidosis? Select all that apply. One, some, or all responses may be correct.
Confusion
Hyperactivity
Excessive thirst
Fruity-scented breath
Decreased urinary output
Confusion, Excessive thirst, Fruity-scented breath
Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). Diabetic ketoacidosis develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to diabetic ketoacidosis if untreated. Signs and symptoms include confusion, excessive thirst, fruity-scented breath, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, and shortness of breath. Weakness or fatigue, not hyperactivity, is a symptom. Frequent urination, not decreased urination, is a symptom.
Which insulin will the nurse prepare for the emergency treatment of ketoacidosis?
A. Glargine
B. NPH insulin
C. Insulin aspart
D. Insulin detemir
C. Insulin aspart
Insulin aspart is a rapid-acting insulin (within 10–20 minutes) and is used to meet a client’s immediate insulin needs. Glargine is a long-acting insulin, which has an onset of 1.5 hours; for diabetic ketoacidosis, the individual needs rapid-acting insulin. NPH insulin is an intermediate-acting insulin, which has an onset of 1 to 2 hours; for diabetic ketoacidosis, the individual needs rapid-acting insulin. Insulin detemir is a long-acting insulin; for diabetic ketoacidosis, the individual needs rapid-acting insulin.
A child with type 1 diabetes is exhibiting deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. Which blood pH and glucose level would the nurse expect the laboratory tests to reveal?
7.20 and 60 mg/dL (3.3 mmol/L)
7.50 and 60 mg/dL (3.3 mmol/L)
7.50 and 460 mg/dL (25.5 mmol/L)
7.20 and 460 mg/dL (25.5 mmol/L)
7.20 and 460 mg/dL (25.5 mmol/L)
A pH of 7.20 and blood glucose level of 460 mg/dL (25.5 mmol/L) are expected values in ketoacidosis; the pH of 7.20 indicates acidosis (metabolic), and the blood glucose level of 460 mg/dL (25.5 mmol/L) is higher than the expected range of 90 to 110 mg/dL (5.0–6.1 mmol/L). Although the blood pH of 7.20 indicates acidosis, the blood glucose of 60 mg/dL (3.3 mmol/L) is less than the expected range of 90 to 110 mg/dL (5.0–6.1 mmol/L), indicating hypoglycemia rather than hyperglycemia. Neither the pH of 7.50 nor the blood glucose value of 60 mg/dL (3.3 mmol/L) is expected with ketoacidosis; with ketoacidosis, the pH is decreased, and the blood glucose level is increased. Although the blood glucose is increased with ketoacidosis, the pH is decreased, not increased; a pH of 7.50 indicates alkalosis.
When receiving hemodialysis, the client may develop hyponatremia. Which clinical findings related to the potential development of hyponatremia would the nurse monitor? Select all that apply. One, some, or all responses may be correct.
A. Diarrhea
B. Seizures
C. Chvostek sign
D. Cardiac dysrhythmias
E. Increased temperature
A. Diarrhea & B. Seizures
Sodium is the most abundant cation in the extracellular fluid and functions as part of the sodium/potassium pump. In the presence of a deficit, the client will exhibit confusion, lethargy, diarrhea, and seizures. Spasm of the facial muscles after a tap over the facial nerve (Chvostek sign) indicates hypocalcemia. Cardiac dysrhythmias are associated with increases or decreases in potassium and calcium. An increase in body temperature reflects a possible infection, not an electrolyte imbalance.
Which nursing intervention is appropriate when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
A. Providing oxygen
B. Encouraging carbohydrates
C. Administering fluid replacement
D. Teaching facts about dietary principles
C. Administering fluid replacement
Rationale: As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.