Question 1 of 6
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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?
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- Impaired Gas ExchangeImpaired Gas Exchange is associated with dysrhythmias but not hypotension.
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- HyperventilationHyperventilation is associated with dysrhythmias but not hypotension. It is also often associated with acute confusion.
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- Excess acid productionExcess acid production is associated with hypotension and dysrhythmias as well as Kussmaul respirations.
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- Excess serum bicarbonateExcess serum bicarbonate is associated with hypotension and dysrhythmias but not Kussmaul respirations.
Question 2 of 6
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Which additional cues would the nurse expect when caring for a patient with Acute Confusion associated with respiratory alkalosis?
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- Muscle crampingHyperventilation can cause muscle cramping as a result of hypocalcemia. This respiratory alkalosis is also associated with tachypnea, lightheadedness, numbness and tingling of extremities, paresthesia, palpitations, cardiac dysrhythmias, anxiety, restlessness, and decreased level of consciousness.
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- RestlessnessHyperventilation can be associated with restlessness and is also associated with tachypnea, lightheadedness, numbness and tingling of extremities, paresthesia, muscle cramping, palpitations, cardiac dysrhythmias, anxiety, and decreased level of consciousness.
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- TachypneaAcute Confusion with respiratory alkalosis is associated with tachypnea or Hyperventilation. It is also associated with lightheadedness, numbness and tingling of extremities, paresthesia, muscle cramping, palpitations, cardiac dysrhythmias, anxiety, restlessness, and decreased level of consciousness.
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- Abdominal painAbdominal pain may be found in a patient with excess acid production along with headache, weakness, nausea, anorexia, Kussmaul respirations, tachycardia, cardiac dysrhythmias, hypotension, decreased level of consciousness (confusion, lethargy, stupor, and coma), and vomiting.
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- NauseaNausea is often found in patients with metabolic acidosis as a result of excess acid production.
Question 3 of 6
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Match each hypothesis with the acid-base imbalance.
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic acidosis
- Metabolic alkalosis
Question 4 of 6
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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?
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- HydrationEvaluating hydration relates indirectly to blood pressure, but it would not provide information specific to the goal of returning blood pressure to baseline or WNL within 24 hours of admission.
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- Vital signsVital signs would provide blood pressure readings to confirm that the goal has been reached.
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- Fluid balanceFluid balance relates indirectly to blood pressure, but it would not provide information specific to the goal of returning blood pressure to baseline or WNL within 24 hours of admission.
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- Respiratory statusRespiratory status would not provide information specific to the goal of returning blood pressure to baseline or WNL within 24 hours of admission.
Question 5 of 6
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Which solutions are appropriate for a nurse to include in the plan of care for a diabetic patient with metabolic acidosis?
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- Decrease blood sugarDecreased blood sugar is an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. These patients present with elevated blood glucose levels.
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- Return to normal vital signsVital signs is not a specific outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis.
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- Replace fluid lossReplacing fluid loss is an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. These patients often have a fluid deficit of as much as 6 L in severe cases.
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- Improve memoryMemory is not an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis.
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- Correct electrolyte imbalancesCorrecting electrolyte imbalances is an outcome the nurse would include in the plan of care for the hypothesis of excess acid production secondary to diabetes mellitus causing metabolic acidosis. These patients often have potassium imbalances.
Question 6 of 6
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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?
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- Patient will verbalize feelings of increased energy within 24 hours of admission.This goal is specific, measurable, and related to fatigue.
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- Patient will seek information about the plan of care at the time of admission.This goal is not measurable and is not related to fatigue. This could be corrected by adding a time frame and a focus on fatigue.
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- Patient will find time to nap between treatment sessions.While this goal is patient-centered, it is not specific or measurable. This could be corrected by adding the duration of naps and how many would take place in a fixed amount of time.
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- Patient will quit smoking within 3 months.This goal is not measurable and is not related to fatigue.