MSN Exam for Fluid, Electrolyte, and Acid Base Problems

EXPLANATION

✔Correct answer:

Hyperthermia. Based on the findings, the most accurate nursing assessment is hyperthermia. Hyperthermia refers to an elevated body temperature, which is present in this patient with a temperature of 100 °F and complaints of fever and chills. While 100 °F is only a mild fever, it is still above the normal body temperature range (97-99 °F) and, therefore, indicates hyperthermia.

Interpretation of Arterial Blood Gas (ABG) Results:

• pH 7.37: This is within the normal range of 7.35-7.45, indicating a balanced acid-base status.
• PaCO₂ 40 mm Hg: This is within the normal range of 35-45 mm Hg, indicating normal respiratory function.
• HCO₃⁻ 24 mmol/L: This is within the normal range of 22-26 mmol/L, indicating normal metabolic function.

These ABG values show that there is no acid-base imbalance, such as respiratory alkalosis or acidosis, and the patient’s acid-base status is within normal limits.

Clinical Context:

• The patient’s symptoms (feeling feverish, experiencing chills) and a slightly elevated body temperature (100 °F) indicate hyperthermia.
• Although the patient’s respiratory rate is noted to be deep, the ABG values are normal, which rules out respiratory alkalosis or acidosis. The body may naturally increase respiratory depth during a fever to help regulate temperature, but it has not altered the pH.

Think of the body’s temperature as a “thermostat setting.” In this case, the setting is slightly higher than normal, but all other systems (like blood gases) are stable and balanced.

The focus of nursing care should be on addressing the fever and assessing for any underlying infection or inflammation.

• Administer antipyretics as prescribed to help reduce fever if it becomes uncomfortable for the patient.
• Encourage hydration to prevent dehydration, as fever can increase fluid loss.
• Monitor for signs of infection, as fever and chills are often associated with an infectious process.
• Educate the patient on managing fever at home, such as with cool compresses and staying hydrated.

✘Incorrect answer options:

Hypothermia and Respiratory Alkalosis: This is incorrect because the patient’s temperature is elevated (100 °F), indicating hyperthermia, not hypothermia. Additionally, the ABG values show no signs of respiratory alkalosis, as the pH and PaCO₂ are within normal limits.

Hypothermia: This is incorrect because hypothermia refers to a body temperature below the normal range, typically under 95 °F. The patient’s temperature of 100 °F indicates mild hyperthermia (fever), not hypothermia.

Hyperthermia and Respiratory Alkalosis: This is incorrect because, while the patient does have mild hyperthermia, there is no evidence of respiratory alkalosis. The ABG values are all within normal limits, showing balanced acid-base status.

EXPLANATION

✔Correct answer:

Collapsed or flattened jugular veins when the client is lying down. Flattened or collapsed jugular veins when the client is in a supine position can indicate hypovolemia, which contributes to decreased cardiac output. Normally, in a lying position, the jugular veins should be distended due to the effect of gravity. However, when plasma volume is reduced, there is insufficient blood volume to fill the veins, resulting in the appearance of collapsed or flattened jugular veins. This finding is consistent with decreased cardiac output due to reduced circulating blood volume.

Reduced plasma volume decreases the preload, or the volume of blood returning to the heart, which in turn lowers stroke volume (the amount of blood pumped out with each beat). With less volume, the heart cannot generate adequate output to meet the body's demands, leading to the manifestation of symptoms like collapsed jugular veins, fatigue, hypotension, and tachycardia as compensatory responses.

Imagine a balloon partially filled with water (reduced plasma volume) connected to a hose (veins). When there’s not enough water, the balloon appears deflated or collapsed. Similarly, when plasma volume is low, the veins—particularly the jugular veins—look flat or collapsed due to insufficient blood volume.

The nurse should continue to monitor for additional signs of decreased cardiac output and intervene to address volume status as per physician orders.

• Monitor vital signs, especially blood pressure and heart rate, to assess for hypotension and compensatory tachycardia.
• Assess for other signs of decreased perfusion, such as delayed capillary refill, cool extremities, and altered mental status.
• Administer fluids as ordered to support plasma volume and improve cardiac output.
• Document intake and output to evaluate fluid balance and monitor for signs of fluid overload or deficit.
• Educate the client on signs of fluid loss and the importance of maintaining hydration, as appropriate.

✘Incorrect answer options:

Vigorous, bounding pulses in the pedal and post-tibial regions. Bounding pulses are typically associated with fluid overload or increased blood volume, which is contrary to the diagnosis of decreased cardiac output due to reduced plasma volume. Bounding pulses indicate a higher-than-normal blood volume or increased cardiac workload, not hypovolemia.

Presence of pitting edema in the feet, ankles, and calves. Pitting edema generally results from fluid retention in the interstitial spaces, often seen in conditions of fluid overload or heart failure. In a scenario of decreased plasma volume, there is insufficient fluid in circulation to cause pitting edema. Therefore, this sign does not align with reduced plasma volume.

Shallow breathing accompanied by crackling sounds upon lung auscultation. Crackles in the lungs are usually indicative of fluid accumulation in the pulmonary system, commonly seen in fluid overload or congestive heart failure. Reduced plasma volume would not typically lead to pulmonary congestion, as there is not enough fluid in circulation to back up into the lungs. Thus, this choice does not support a diagnosis of decreased cardiac output due to hypovolemia.

EXPLANATION

✔Correct answer:

Raise the ventilator rate settings from 6 to 10 breaths per minute. Increasing the ventilator rate (respiratory rate) is the most effective intervention to address respiratory acidosis. Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO₂) in the blood, often due to hypoventilation or inadequate ventilation. By increasing the ventilator rate, the patient will receive more breaths per minute, which helps to remove more CO₂ from the lungs. This increase in ventilation can help to "blow off" the excess CO₂, thus correcting the acidosis and improving the arterial blood gas (ABG) values.

Respiratory acidosis results from an increase in CO₂ levels, which combines with water in the body to form carbonic acid, lowering the pH and leading to acidemia. By increasing the respiratory rate, more CO₂ is expelled with each breath, helping to reduce blood CO₂ levels and, consequently, the acidosis. This intervention is particularly important for patients on mechanical ventilation, where settings can be adjusted to optimize gas exchange.

Think of CO₂ buildup like smoke filling a room. If you increase the ventilation (opening windows wider or using more fans), more smoke will be pushed out, clearing the air faster. Similarly, raising the ventilator rate allows more CO₂ to be "vented out" from the patient's lungs, reducing respiratory acidosis.

After increasing the ventilator rate, Nurse Sarah should closely monitor the patient's ABG results and clinical response to ensure the intervention is effective and well-tolerated.

• Check ABG values regularly to assess whether CO₂ levels are decreasing and pH is normalizing.
• Observe the patient’s respiratory status and work of breathing, ensuring the increased rate is well tolerated.
• Collaborate with the respiratory therapist to make fine-tuned adjustments as needed to achieve optimal ventilation.
• Monitor for potential signs of respiratory alkalosis (e.g., dizziness, tingling) if CO₂ levels drop too low from excessive ventilation rate adjustments.
• Document all ventilator adjustments and monitor the patient’s response to track progress and outcomes.

✘Incorrect answer options:

Reduce the ventilator rate settings from 10 to 6 breaths per minute. Lowering the ventilator rate would reduce the number of breaths per minute, leading to hypoventilation and allowing CO₂ to accumulate further. This would worsen respiratory acidosis, as it would increase CO₂ retention.

Lower the oxygen concentration settings from 40% to 30%. Adjusting the oxygen concentration (FiO₂) primarily affects oxygenation, not ventilation or CO₂ removal. Reducing the FiO₂ would decrease the amount of oxygen delivered to the patient, which would not address the problem of respiratory acidosis caused by CO₂ retention.

Increase the oxygen concentration settings from 30% to 40%. Increasing FiO₂ would improve the oxygen levels in the blood, but it would not help to "blow off" CO₂ or correct respiratory acidosis. Oxygen concentration adjustments are used to address hypoxemia, not hypercapnia (elevated CO₂ levels).

EXPLANATION

✔Correct answer:

Monitor vital signs at 15-minute intervals. Monitoring vital signs at regular intervals, such as every 15 minutes, is an appropriate task to delegate to a nursing assistant in the context of diabetic ketoacidosis (DKA). While DKA is a serious condition that requires close monitoring, checking and recording vital signs is within the scope of practice for a nursing assistant. They can take the client’s blood pressure, heart rate, respiratory rate, and temperature, which provides valuable information for the healthcare team. The registered nurse (RN) remains responsible for interpreting these vital signs in the context of the client's condition and adjusting the care plan as needed.

According to delegation guidelines, tasks that are routine, repetitive, and do not require clinical judgment or critical decision-making are suitable for delegation to nursing assistants. Monitoring vital signs falls within this category, while more complex tasks involving assessment, medication administration, and critical monitoring (such as blood glucose checks in DKA) should remain the responsibility of licensed nursing personnel.

Think of the nursing assistant as a weather observer who reports the temperature and wind conditions regularly, while the nurse acts as the meteorologist who interprets those reports and determines if any action is needed based on the patterns observed.

Nurse Tim should ensure that the nursing assistant understands the importance of timely and accurate recording of vital signs and should provide clear instructions on reporting any concerning values immediately.

• Instruct the nursing assistant to report any abnormal or concerning vital signs (e.g., significant changes in heart rate, blood pressure, or respiratory rate) promptly to the nurse.
• Document all vital signs in the client’s chart, as they provide essential data for evaluating the effectiveness of treatment for DKA.
• Encourage the nursing assistant to check for client comfort and safety during each vital sign assessment.
• Reinforce the importance of adhering to the 15-minute interval to monitor for any rapid changes in the client’s condition, as DKA can cause sudden shifts in status.

✘Incorrect answer options:

Evaluate for signs pointing to fluid imbalance. Assessing for fluid imbalance requires clinical judgment and the ability to interpret subtle signs and symptoms, such as changes in skin turgor, mucous membranes, urine output, and overall hemodynamic status. This task is within the scope of practice for the RN, not the nursing assistant, as it involves assessment skills and critical thinking.

Administer intravenous insulin as ordered. Administering IV medications, including insulin, requires a licensed nurse’s expertise. Insulin administration in DKA is critical and involves close monitoring of blood glucose levels and titration of insulin doses. This task is outside the scope of practice for a nursing assistant.

Perform hourly fingerstick glucose tests. Checking blood glucose levels is an essential monitoring task in the management of DKA, and it requires skill and precision to obtain accurate readings. Fingerstick glucose testing in critically ill patients is typically performed by licensed nursing staff to ensure timely adjustments to insulin and fluid therapy based on the results. This task is not appropriate to delegate to a nursing assistant in the context of DKA.

EXPLANATION

✔Correct answer:

Respiratory Alkalosis, Uncompensated. The ABG results indicate uncompensated respiratory alkalosis. Let’s analyze each component of the ABG to understand this assessment:

1. pH 7.6: This is above the normal range of 7.35-7.45, indicating alkalosis.
2. PaCO₂ 31 mm Hg: This is below the normal range of 35-45 mm Hg, suggesting that the alkalosis is due to a respiratory cause (hyperventilation), as low PaCO₂ indicates a loss of carbon dioxide, which is acidic. The low CO₂ level confirms that the primary issue is respiratory.
3. HCO₃⁻ 25 mmol/L: This is within the normal range of 22-26 mmol/L, indicating that the kidneys have not started to compensate for the alkalosis by adjusting bicarbonate levels. Therefore, this is an uncompensated condition.

Additional clinical symptoms, such as muscle cramps, tingling, paraesthesia, tachycardia, and tachypnea, support the diagnosis of respiratory alkalosis. These symptoms can result from hyperventilation, which often leads to decreased CO₂ and an elevated pH (alkalosis). Sheila may be hyperventilating due to pain, anxiety, or possibly even an underlying injury-related stress response.

Imagine carbon dioxide (CO₂) as a "brake" that keeps the body's pH balanced. Hyperventilating is like releasing the brake too much, leading to a rapid rise in pH (alkalosis). Because this is a respiratory issue, it hasn't given the kidneys time to adjust yet, making it uncompensated.

In this case, Nurse Sheila should work to identify and address the underlying cause of hyperventilation to correct the respiratory alkalosis.

• Encourage Sheila to take slow, deep breaths to reduce hyperventilation and increase CO₂ levels, which will help bring the pH back toward normal.
• Address pain control to help reduce any pain-induced anxiety or hyperventilation. Ensure that Sheila's pain is managed effectively with appropriate analgesics.
• Monitor Sheila’s respiratory rate and ABG levels to assess for improvement or worsening of her acid-base status.
• Provide a calm environment to help reduce any anxiety that might be contributing to hyperventilation.
• Educate Sheila on relaxation techniques, if appropriate, to help manage her breathing and reduce anxiety-related hyperventilation.

✘Incorrect answer options:

Respiratory Acidosis, Partially Compensated: This is incorrect because the ABG values indicate alkalosis, not acidosis. The elevated pH and low PaCO₂ confirm an alkalotic state, not an acidosis. Additionally, compensation is not present here.

Metabolic Alkalosis, Uncompensated: This is incorrect because the primary cause of the alkalosis is respiratory, as indicated by the low PaCO₂, not metabolic. In metabolic alkalosis, we would expect an elevated HCO₃⁻ rather than a change in PaCO₂.

Metabolic Alkalosis, Partially Compensated: This is also incorrect because there is no indication of metabolic involvement in the alkalosis. The bicarbonate level is normal, which rules out metabolic causes, and there is no partial compensation here.

EXPLANATION

✔Correct answer:

24 mmol/L. The standard reference range for bicarbonate (HCO₃⁻) in arterial blood is typically 22-26 mmol/L, with 24 mmol/L considered an ideal midpoint. Bicarbonate is an important buffer in the body that helps maintain the pH balance by neutralizing excess acids. Deviations from this range can indicate metabolic disturbances that affect the acid-base balance.

In this case, the patient's HCO₃⁻ level of 5 mmol/L is well below the normal range, indicating a severe metabolic acidosis. The extremely low bicarbonate level, along with the low pH of 7.1, confirms a state of acidosis. The low PaCO₂ of 16 mm Hg suggests that the body is attempting to compensate through hyperventilation to expel CO₂ (an acid), thereby raising the pH.

Summary of ABG Results and Clinical Implications:

• pH of 7.1: Indicates severe acidosis.
• PaCO₂ of 16 mm Hg: This is below the normal range (35-45 mm Hg), showing that the body is compensating by "blowing off" CO₂ to counter the acidosis.
• HCO₃⁻ of 5 mmol/L: This is significantly below the normal range of 22-26 mmol/L, confirming a primary metabolic acidosis.

The most likely diagnosis, given these findings, is severe metabolic acidosis with compensatory respiratory alkalosis (due to hyperventilation).

Bicarbonate (HCO₃⁻) acts like a "buffer sponge" in the blood, soaking up excess acid. With a level this low, the buffer is almost depleted, causing the blood to become very acidic.

This patient requires urgent interventions to address the severe metabolic acidosis and prevent further complications.

• Administer IV bicarbonate as prescribed to help correct the metabolic acidosis and increase blood pH.
• Monitor ABGs and electrolytes frequently to assess the effectiveness of treatment and ensure that the acid-base balance is improving.
• Identify and treat the underlying cause of the metabolic acidosis, such as renal failure, diabetic ketoacidosis, or sepsis.
• Provide supportive care, including monitoring respiratory function and ensuring adequate oxygenation, as the body may be working hard to compensate.

✘Incorrect answer options:

20 mmol/L: This is below the standard reference range for bicarbonate (22-26 mmol/L) and would indicate a mild decrease, but it is not considered within the normal range.

29 mmol/L: This is above the normal reference range for bicarbonate. While it does not indicate a dangerously high level, it is outside the standard range of 22-26 mmol/L.

31 mmol/L: This is also above the normal reference range and would indicate a higher-than-normal bicarbonate level, which might be seen in cases of metabolic alkalosis.

EXPLANATION

✔Correct answer:

Give 15 g of Kayexalate orally. Administering Kayexalate (sodium polystyrene sulfonate) can be safely delegated to a student nurse under the supervision of an experienced nurse like Sarah. Kayexalate is a medication used to treat hyperkalemia by binding to potassium in the gastrointestinal tract and promoting its excretion in the stool. In a supervised setting, student nurses can safely administer oral medications like Kayexalate, which does not require advanced assessment skills. This task provides the student with practical experience in managing electrolyte imbalances under the guidance of a licensed nurse.

According to the principles of delegation in nursing, tasks that are routine, do not require complex assessment, and have predictable outcomes are appropriate for delegation to student nurses under supervision. Since oral administration of Kayexalate is straightforward and does not involve direct clinical judgment (unlike evaluating ECGs or adjusting potassium-influencing medications), it can be an appropriate learning opportunity for the student nurse.

Think of Kayexalate as a sponge that soaks up extra potassium in the digestive system, allowing it to be removed through bowel movements. Giving Kayexalate is like giving a patient a "potassium sponge" to help lower high potassium levels in a controlled, predictable manner.

Before administering Kayexalate, the nurse should provide the student nurse with instructions and ensure close monitoring of the patient's response to the medication.

• Instruct the student nurse on the correct dosage and method of administration for Kayexalate.
• Monitor the patient's bowel movements, as Kayexalate can cause constipation and gastrointestinal discomfort.
• Educate the patient on the purpose of Kayexalate and potential side effects, such as loose stools.
• Observe for clinical improvement in hyperkalemia symptoms and be prepared to assess potassium levels post-administration.
• Ensure that the student nurse reports any adverse effects or concerns noted during the administration process.

✘Incorrect answer options:

Evaluate the ECG strip for heightened T waves. ECG interpretation requires clinical expertise and knowledge of normal and abnormal waveforms, especially in critical conditions like hyperkalemia. Identifying elevated T waves requires advanced assessment skills, which is beyond the scope of practice for a student nurse. Only a licensed nurse or healthcare provider should interpret ECG findings.

Give 10 mEq of potassium orally. Administering additional potassium to a patient with hyperkalemia (elevated potassium) is contraindicated, as it would worsen the patient's condition. This task would not be appropriate for anyone in this situation, including a student nurse. The correct intervention should involve lowering potassium levels, not increasing them.

Give 25 mg of spironolactone orally. Spironolactone is a potassium-sparing diuretic, meaning it can increase potassium levels in the body. Administering this medication to a patient with hyperkalemia is contraindicated, as it could further raise potassium levels. This medication should not be administered to a hyperkalemic patient, and thus would not be appropriate to delegate to a student nurse.

EXPLANATION

✔Correct answer:

Metabolic Acidosis, Fully Compensated The ABG results indicate fully compensated metabolic acidosis. Let’s analyze each component to understand why this is the correct interpretation.

1. pH 7.39: This is at the lower end of the normal range (7.35-7.45), indicating a near-normal pH but on the acidic side. A pH close to 7.40 with a low bicarbonate (HCO₃⁻) suggests that the body has compensated for an acidosis.
2. PaCO₂ 27 mm Hg: This is below the normal range of 35-45 mm Hg, indicating that Baby Sophia is "blowing off" CO₂ as a compensatory mechanism. A low PaCO₂ suggests that the respiratory system is compensating by hyperventilating to decrease CO₂, which helps to raise the pH.
3. HCO₃⁻ 19 mEq/L: This is below the normal range of 22-26 mEq/L, indicating a primary metabolic acidosis (a lower-than-normal bicarbonate level).

Baby Sophia’s symptoms of fussiness, poor feeding, diarrhea, and signs of dehydration (e.g., high respiratory rate and sunken fontanels) are consistent with a metabolic acidosis, likely due to dehydration and bicarbonate loss from diarrhea. Diarrhea can lead to the loss of bicarbonate ions, resulting in metabolic acidosis. The low HCO₃⁻ confirms that the primary problem is metabolic acidosis, while the low PaCO₂ indicates that the respiratory system has fully compensated for the acidosis by increasing the respiratory rate to "blow off" CO₂.

Since the pH is within the normal range, this is considered fully compensated metabolic acidosis.

Think of bicarbonate as a "buffer" that neutralizes acid in the body. Losing bicarbonate through diarrhea leaves the body with too much acid. To balance this, the lungs try to remove acidic CO₂, resulting in a normal pH despite the underlying acidosis.

Nurse Emily should prioritize interventions to address the underlying cause of the metabolic acidosis, which appears to be dehydration and bicarbonate loss due to diarrhea.

• Administer intravenous fluids as prescribed to treat dehydration and restore electrolyte balance.
• Monitor electrolyte levels, particularly bicarbonate, to evaluate the resolution of metabolic acidosis.
• Encourage breastfeeding or formula feeding if possible, as appropriate, to help with hydration and nutrition.
• Educate the mother on signs of dehydration and the importance of seeking prompt care if symptoms recur.
• Observe the baby’s respiratory rate, hydration status, and fontanels for improvements as fluid balance is restored.

✘Incorrect answer options:

Respiratory Alkalosis, Fully Compensated: This is incorrect because the primary problem here is metabolic, not respiratory. The low bicarbonate (HCO₃⁻) level indicates metabolic acidosis, not respiratory alkalosis.

Respiratory Acidosis, Uncompensated: This is incorrect because the PaCO₂ is low, which indicates hyperventilation, not CO₂ retention. Respiratory acidosis would involve an elevated PaCO₂, and the pH would be acidic without compensation, which is not the case here.

Metabolic Acidosis, Uncompensated: This is incorrect because the body has fully compensated for the metabolic acidosis, as evidenced by the near-normal pH. If it were uncompensated, the pH would remain below 7.35 without evidence of respiratory compensation.

EXPLANATION

✔Correct answer:

Metabolic Alkalosis, Uncompensated The ABG results indicate uncompensated metabolic alkalosis. Let’s analyze each component to understand why this is the correct interpretation.

1. pH 7.5: This is above the normal range of 7.35-7.45, indicating alkalosis.
2. PaCO₂ 40 mm Hg: This is within the normal range of 35-45 mm Hg, suggesting that there is no respiratory compensation taking place. If the body were compensating for metabolic alkalosis, we would expect a slight increase in PaCO₂ due to hypoventilation, which would help to bring the pH back toward normal.
3. HCO₃⁻ 34 mmol/L: This is elevated above the normal range of 22-26 mmol/L, indicating that the alkalosis is due to a metabolic cause, as bicarbonate levels are high.

Mark’s grandmother has been vomiting for two days, which is a significant clue. Vomiting causes a loss of gastric acid (hydrochloric acid), leading to a reduction in hydrogen ions (H⁺) in the blood, which increases the blood’s pH, resulting in metabolic alkalosis. The elevated HCO₃⁻ level further supports the diagnosis of metabolic alkalosis. Since the PaCO₂ remains normal, there has been no respiratory compensation.

Imagine acid in the stomach as a "balancing weight" that helps keep pH levels stable. Vomiting removes this acid (the balancing weight), making the blood more alkaline. Since the lungs haven't adjusted their breathing pattern (no change in PaCO₂), the body hasn't tried to compensate yet.

Nurse interventions should focus on treating the underlying cause (vomiting and dehydration) and monitoring for signs of worsening alkalosis.

• Administer intravenous fluids as ordered to correct dehydration and replenish electrolytes lost due to vomiting.
• Monitor electrolyte levels, particularly potassium, as hypokalemia is common in metabolic alkalosis due to vomiting.
• Provide antiemetics as prescribed to control vomiting and prevent further loss of gastric acid.
• Monitor the client’s ABG values and watch for signs of respiratory compensation if the metabolic alkalosis persists.
• Educate the client and family on the importance of hydration and dietary modifications once vomiting subsides.

✘Incorrect answer options:

Metabolic Alkalosis, Partially Compensated: This is incorrect because there is no indication of partial compensation. The PaCO₂ is within the normal range, meaning the respiratory system has not yet adjusted to compensate for the metabolic alkalosis. For partial compensation, we would expect a slight elevation in PaCO₂.

Respiratory Alkalosis, Uncompensated: This is incorrect because the primary issue here is metabolic, not respiratory. Respiratory alkalosis would be indicated by a low PaCO₂, which is not the case here. The high HCO₃⁻ points to a metabolic cause.

Respiratory Acidosis, Partially Compensated: This is incorrect because the pH is alkaline (above 7.45), not acidic. Respiratory acidosis would be associated with a low pH and high PaCO₂, which are not present in these results.

EXPLANATION

✔Correct answer:

Metabolic Acidosis. Susan’s elderly mother is most at risk for metabolic acidosis due to the large quantity of aspirin (salicylate) she ingested. Aspirin overdose is a well-known cause of metabolic acidosis. Salicylates, the active component of aspirin, are acidic compounds. When taken in large amounts, they increase the production of acid in the body and lower blood pH, leading to metabolic acidosis.

Pathophysiology of Salicylate Toxicity:

• Salicylates stimulate metabolic processes that produce lactic acid and other acidic by-products, contributing to an acidic environment in the bloodstream.
• Additionally, salicylates increase respiratory rate, as seen here with her respiration rate of 32 and deep breathing. This hyperventilation is the body’s compensatory mechanism, attempting to “blow off” CO₂ to help balance the pH temporarily. This type of deep and rapid breathing is known as Kussmaul respirations, which are often seen in metabolic acidosis.

Clinical Context:

• The respiratory rate of 32 breaths per minute indicates a compensatory response to the acidosis. As metabolic acidosis develops, the body tries to compensate by increasing the respiratory rate to reduce CO₂, which is acidic, thereby helping to elevate the blood pH.
• If left untreated, the acidosis can worsen, leading to severe complications such as confusion, lethargy, organ dysfunction, or even death.

Think of the blood as a solution with a balanced pH. When too much acid (like aspirin) is added, it makes the solution more acidic. The body tries to balance this by “venting” the acid through rapid, deep breathing, but without intervention, the acid level continues to rise.

Nurse interventions should focus on neutralizing the acid and removing the salicylates from the body.

• Administer sodium bicarbonate as ordered to neutralize the acid and increase blood pH.
• Promote elimination of salicylates through hydration and, if necessary, consider hemodialysis for severe toxicity to quickly remove salicylates from the bloodstream.
• Monitor electrolyte levels and ABG values frequently to assess for worsening acidosis or emerging electrolyte imbalances.
• Observe for signs of worsening acidosis, such as changes in mental status, confusion, or lethargy.
• Educate Susan and her family on the risks of aspirin overdose and the importance of adhering to proper dosing, especially in elderly patients.

✘Incorrect answer options:

Respiratory Acidosis: This is incorrect because respiratory acidosis is characterized by an accumulation of CO₂ due to hypoventilation. In this case, the woman is hyperventilating, which indicates an attempt to compensate for a primary metabolic acidosis, not a respiratory cause.

Metabolic Alkalosis: This is incorrect because metabolic alkalosis is usually caused by factors such as excessive vomiting or diuretic use, which lead to a loss of acids or an increase in bicarbonate. Aspirin overdose does not cause metabolic alkalosis; rather, it leads to metabolic acidosis.

Respiratory Alkalosis: This is incorrect because respiratory alkalosis would result from hyperventilation in the absence of a metabolic disturbance. Although the woman is hyperventilating, it is a compensatory response to metabolic acidosis, not a primary respiratory alkalosis.

EXPLANATION

✔Correct answer:

A respiratory rate ranging between 8 to 10 breaths per minute. A respiratory rate of 8 to 10 breaths per minute is a concerning finding that should be reported immediately. Oxycodone, an opioid analgesic, has a known side effect of respiratory depression. Opioids act on the central nervous system by binding to opioid receptors, which can decrease the respiratory drive, especially in opioid-naïve patients or at higher doses. A respiratory rate below 12 breaths per minute is generally considered a sign of respiratory depression and should prompt close monitoring and possible intervention. If the rate drops to 8 to 10 breaths per minute, there is a risk of hypoxia, and the patient may need prompt medical intervention to prevent further decline.

Opioids, such as oxycodone, can depress the central respiratory centers in the brainstem, leading to slower and shallower breathing. This effect can be particularly dangerous in clients with underlying respiratory issues, such as lung cancer patients who may already have compromised lung function. Identifying and responding quickly to signs of respiratory depression is essential in managing opioid use safely.

Think of opioids like a dimmer switch on a light bulb (the breathing center). Turning the dimmer too low can make the light (breathing) barely visible, so keeping it within a safe range prevents the light from going out.

Nurse Ethan should instruct the student nurse to closely monitor the client's respiratory status and be prepared to take appropriate actions in case of further respiratory decline.

• Continue monitoring respiratory rate and oxygen saturation frequently (e.g., every 5-15 minutes) until it stabilizes above 12 breaths per minute.
• If respiratory rate continues to decline, prepare to administer supplemental oxygen and notify the healthcare provider promptly.
• Have naloxone (Narcan) readily available as an opioid reversal agent in case of severe respiratory depression.
• Educate the student nurse about the importance of monitoring for other signs of opioid overdose, such as sedation, pinpoint pupils, or altered mental status.
• Document the findings and any actions taken to ensure accurate records and continuity of care.

✘Incorrect answer options:

A drop in pain level from 6/10 to 2/10. A reduction in pain level from 6/10 to 2/10 indicates that the oxycodone is effectively managing the client’s pain. This is a desired outcome and does not require immediate reporting.

The client asked for the room door to be shut. A request to close the door may simply reflect a need for privacy or a preference for a quieter environment. This is a non-urgent request that does not indicate any complications from the medication.

Heart rate fluctuating between 90-100 beats per minute. A heart rate between 90-100 beats per minute is within a tolerable range for most adults and does not indicate an immediate concern related to oxycodone administration. Minor fluctuations in heart rate are common and do not require urgent reporting unless accompanied by other symptoms such as arrhythmias or chest pain.

EXPLANATION

✔Correct answer:

Suspected respiratory alkalosis. The client’s elevated respiratory rate of 38 breaths per minute suggests respiratory alkalosis. When a person breathes rapidly (hyperventilates), they exhale more carbon dioxide (CO₂) than usual, which reduces the levels of CO₂ in the blood. Since CO₂ is acidic, a decrease in its concentration results in an increase in blood pH, leading to alkalosis. Respiratory alkalosis is often triggered by anxiety or panic attacks, as these conditions can lead to rapid, shallow breathing (hyperventilation).

In respiratory alkalosis, the loss of CO₂ due to hyperventilation causes a drop in carbonic acid levels, resulting in a rise in blood pH (alkalosis). The kidneys may eventually try to compensate by excreting bicarbonate to balance the pH, but this process takes time. In acute situations, hyperventilation can cause symptoms such as dizziness, tingling in the extremities, or even fainting due to the sudden shift in pH.

Imagine CO₂ as a "brake" that helps keep pH balanced in the blood. Hyperventilating is like "releasing the brake" too much, causing the body to become more alkaline than normal.

Nurse Emily should take steps to help the client slow their breathing to retain CO₂ and bring the pH back to normal.

• Encourage the client to practice slow, deep breathing to prevent further loss of CO₂. Instructing them to breathe into a paper bag can help if symptoms are severe, as this can increase CO₂ levels.
• Provide reassurance and a calming environment to reduce anxiety, as addressing the root cause (anxiety) will help normalize the breathing rate.
• Monitor the client’s respiratory rate and re-assess their ABGs (if available) to determine if pH and CO₂ levels are stabilizing.
• Educate the client on stress management techniques to help prevent future episodes of hyperventilation if anxiety is an ongoing issue.

✘Incorrect answer options:

Suspected metabolic alkalosis. Metabolic alkalosis is typically caused by factors such as excessive vomiting, diuretic use, or bicarbonate ingestion, which result in a loss of acid or an increase in base. It is not directly related to rapid breathing or anxiety. Elevated respiratory rate is more consistent with respiratory rather than metabolic causes.

Suspected metabolic acidosis. Metabolic acidosis can result from conditions like kidney failure, diabetic ketoacidosis, or severe diarrhea, which lead to an accumulation of acid or a loss of bicarbonate. In response to metabolic acidosis, the body may increase respiratory rate to "blow off" CO₂ as a compensatory mechanism. However, the primary cause of the elevated respiratory rate in this scenario is anxiety, not metabolic acidosis.

Suspected respiratory acidosis. Respiratory acidosis occurs when CO₂ levels increase due to inadequate ventilation, such as in cases of respiratory depression, lung disease, or airway obstruction. The hallmark of respiratory acidosis is a slow or ineffective respiratory rate, which causes CO₂ retention. An elevated respiratory rate is not characteristic of respiratory acidosis.

EXPLANATION

✔Correct answer:

Respiratory Acidosis, Uncompensated The ABG results indicate uncompensated respiratory acidosis. Let’s analyze each component to understand why this is the correct interpretation.

1. pH 7.10: This is below the normal range of 7.35-7.45, indicating acidosis.
2. PaCO₂ 70 mm Hg: This is significantly elevated above the normal range of 35-45 mm Hg, indicating a respiratory cause for the acidosis. High PaCO₂ indicates that the patient is retaining carbon dioxide, which is acidic, and this is commonly seen in hypoventilation.
3. HCO₃⁻ 24 mEq/L: This is within the normal range of 22-26 mEq/L, indicating that there has been no metabolic compensation. If the kidneys were attempting to compensate, we would expect an increase in bicarbonate (HCO₃⁻) to help buffer the excess CO₂ and raise the pH. Since the HCO₃⁻ level is normal, we know this is uncompensated.

Ms. Emily’s shallow breathing rate of 7 breaths/min is likely due to the effects of the IV morphine sulfate, which is a respiratory depressant. Morphine and other opioids can slow the respiratory rate and depth, leading to CO₂ retention and, consequently, respiratory acidosis. The low pH and high PaCO₂ confirm that the primary problem is respiratory, and the lack of compensation indicates that this is an uncompensated condition.

Imagine CO₂ as "exhaust" in the body. Because Ms. Emily’s breathing is shallow, the "exhaust" is not being expelled properly, causing it to build up. This buildup of CO₂ makes her blood more acidic, creating respiratory acidosis.

Nurse Gabriel should take steps to address Ms. Emily’s respiratory depression and prevent further CO₂ retention.

• Administer oxygen as prescribed to improve oxygenation, but keep in mind that oxygen alone will not correct CO₂ retention. The main goal is to improve ventilation.
• Administer naloxone (Narcan), an opioid antagonist, if ordered, to reverse the effects of the morphine and improve her respiratory drive.
• Monitor Ms. Emily’s respiratory rate, depth, and ABGs closely after administering naloxone to ensure that her respiratory status improves.
• Position Ms. Emily upright to facilitate lung expansion and improve ventilation.
• Document the findings, interventions, and Ms. Emily’s response to treatment, and notify the healthcare provider of the patient’s respiratory status.

✘Incorrect answer options:

Respiratory Alkalosis, Partially Compensated: This is incorrect because the ABG values indicate acidosis, not alkalosis. In respiratory alkalosis, we would expect a high pH (greater than 7.45) and low PaCO₂ (less than 35 mm Hg), which are not present here.

Metabolic Alkalosis, Partially Compensated: This is incorrect because the primary issue is respiratory, not metabolic. Metabolic alkalosis would present with an elevated pH and elevated HCO₃⁻, which are not present here. Additionally, there is no partial compensation here.

Metabolic Acidosis, Uncompensated: This is incorrect because the primary cause of the acidosis is respiratory (elevated PaCO₂), not metabolic. In metabolic acidosis, we would expect a low HCO₃⁻ level as the primary indicator of acidosis, not a high PaCO₂.

EXPLANATION

✔Correct answer:

Respiratory Alkalosis, Uncompensated The ABG results indicate uncompensated respiratory alkalosis. Let’s analyze each component of the ABG to understand why this is the correct interpretation.

1. pH 7.61: This is above the normal range of 7.35-7.45, indicating alkalosis.
2. PaCO₂ 22 mmHg: This is below the normal range of 35-45 mmHg, indicating a loss of carbon dioxide (CO₂). Low PaCO₂ indicates that the alkalosis is due to hyperventilation, as CO₂ is "blown off" during rapid breathing. Since CO₂ is acidic, its reduction causes an increase in pH, leading to alkalosis.
3. HCO₃⁻ 25 mEq/L: This is within the normal range of 22-26 mEq/L, indicating that the kidneys have not yet begun to compensate by altering bicarbonate levels. If the body were compensating, we might expect the HCO₃⁻ to decrease slightly in order to balance the high pH, but it remains unchanged here.

Arvin’s anxiety has led to hyperventilation, which caused a rapid loss of CO₂, leading to respiratory alkalosis. The dizziness and eventual loss of consciousness are symptoms that can result from respiratory alkalosis, as the reduced CO₂ levels cause cerebral vasoconstriction, reducing blood flow to the brain. The normal HCO₃⁻ level confirms that this is an uncompensated condition, as the kidneys have not yet had time to adjust bicarbonate levels.

Think of CO₂ as an "acidic brake" that helps keep the body’s pH in balance. When hyperventilating, Arvin “releases the brake” too much, causing the pH to rise and resulting in alkalosis. Since this is an acute situation, his kidneys haven't had time to respond and compensate.

Nurse interventions should focus on addressing Arvin’s hyperventilation and anxiety to prevent further episodes of respiratory alkalosis.

• Encourage slow, controlled breathing to help retain CO₂ and bring the pH back toward normal. This can be achieved by coaching Arvin to breathe slowly and deeply, or in some cases, using a paper bag if appropriate.
• Provide reassurance to Arvin to help alleviate his anxiety, as reducing anxiety can reduce the tendency to hyperventilate.
• Monitor Arvin’s respiratory rate, level of consciousness, and ABG values to assess for any changes or improvement.
• Educate Arvin on relaxation techniques, such as deep breathing exercises, to help manage preoperative anxiety.
• If hyperventilation continues, consider involving mental health support or administering anti-anxiety medications as prescribed.

✘Incorrect answer options:

Metabolic Acidosis, Uncompensated: This is incorrect because the pH indicates alkalosis, not acidosis. Additionally, metabolic acidosis would be associated with a low HCO₃⁻ level, which is not present here.

Respiratory Alkalosis, Partially Compensated: This is incorrect because the HCO₃⁻ level is normal, indicating no compensation. If partial compensation were present, we would expect to see a decrease in HCO₃⁻ as the kidneys attempt to bring the pH back to normal.

Metabolic Alkalosis, Partially Compensated: This is incorrect because the primary disturbance here is respiratory, not metabolic. Metabolic alkalosis would present with an elevated HCO₃⁻, which is not the case here. The low PaCO₂ confirms that the alkalosis is respiratory in origin.

EXPLANATION

✔Correct answer:

Simultaneous Respiratory and Metabolic Acidosis The ABG results indicate simultaneous respiratory and metabolic acidosis. Let’s break down the values to understand why this is the correct interpretation.

1. pH 6.90: This is well below the normal range of 7.35-7.45, indicating severe acidosis.
2. PaCO₂ 68 mmHg: This is significantly elevated above the normal range of 35-45 mmHg, indicating respiratory acidosis. The high PaCO₂ suggests that the patient is retaining CO₂, likely due to respiratory depression from the ingestion of sleeping pills, which are CNS depressants.
3. HCO₃⁻ 13 mEq/L: This is below the normal range of 22-26 mEq/L, indicating metabolic acidosis. The low bicarbonate level suggests that there is an additional metabolic component to the acidosis, which may be due to tissue hypoxia and lactic acid accumulation resulting from prolonged hypoventilation and reduced oxygenation.

Clinical Context:

• The ingestion of sleeping pills likely caused CNS depression, leading to hypoventilation and CO₂ retention, resulting in respiratory acidosis.
• The low HCO₃⁻ level indicates an additional metabolic acidosis component, possibly due to lactic acidosis from tissue hypoxia caused by inadequate ventilation and oxygenation over a period of time.

Summary of Acid-Base Status:

• The patient’s ABG values show evidence of both respiratory acidosis (high PaCO₂) and metabolic acidosis (low HCO₃⁻) without compensation, as the pH is still critically low at 6.90. This combination of acidosis from both respiratory and metabolic sources makes this case a mixed or simultaneous respiratory and metabolic acidosis.

Think of CO₂ as “acidic exhaust” and bicarbonate as a “buffer sponge.” In this case, there’s too much CO₂ (from respiratory depression) and not enough bicarbonate (from metabolic demands), overwhelming the system and leading to severe acidosis.

The patient requires immediate interventions to address the severe acidosis and prevent further complications.

• Secure the airway and provide ventilatory support as needed, such as intubation and mechanical ventilation, to improve CO₂ clearance and oxygenation.
• Administer sodium bicarbonate as ordered to help buffer the acid and raise blood pH, particularly given the dangerously low pH level.
• Monitor ABGs frequently to assess the effectiveness of interventions and monitor changes in pH, PaCO₂, and HCO₃⁻ levels.
• Administer fluids and other supportive treatments as necessary to address potential causes of metabolic acidosis, such as lactic acidosis.
• Administer reversal agents (e.g., flumazenil if the sleeping pills are benzodiazepines), if appropriate and available, to counteract the effects of the drug overdose.

✘Incorrect answer options:

Respiratory Acidosis with Complete Renal Compensation: This is incorrect because complete renal compensation would result in an elevated HCO₃⁻ to buffer the acidosis and bring the pH closer to normal. Here, the HCO₃⁻ is low, indicating metabolic acidosis rather than compensation.

Respiratory Acidosis: This is incorrect because while respiratory acidosis is present (elevated PaCO₂), the low HCO₃⁻ indicates an additional metabolic acidosis component. This is a mixed acidosis, not a pure respiratory acidosis.

Metabolic Acidosis: This is incorrect because although metabolic acidosis is present (low HCO₃⁻), the elevated PaCO₂ indicates a concurrent respiratory acidosis due to CO₂ retention. This is a mixed acidosis, not a pure metabolic acidosis.

EXPLANATION

✔Correct answer:

Respiratory Acidosis, Fully Compensated The ABG results indicate fully compensated respiratory acidosis. Let’s analyze each component of the ABG values to understand this interpretation.

1. pH 7.35: This is at the lower end of the normal range (7.35-7.45), which indicates a fully compensated acid-base state. While the pH is within the normal range, it is on the acidic side, suggesting an underlying acidosis that has been compensated.
2. PaCO₂ 72 mmHg: This is significantly elevated above the normal range of 35-45 mmHg, indicating that Noah is retaining carbon dioxide (CO₂), which is acidic. A high PaCO₂ is characteristic of respiratory acidosis, likely due to inadequate ventilation related to his respiratory condition (asthma and respiratory distress).
3. HCO₃⁻ 38 mEq/L: This is elevated above the normal range of 22-26 mEq/L, indicating that the kidneys have retained bicarbonate to compensate for the respiratory acidosis. The increased bicarbonate level helps to neutralize the acidotic state caused by CO₂ retention.

Noah's history of asthma and respiratory distress syndrome, along with the elevated PaCO₂, suggests he is experiencing chronic respiratory acidosis. His kidneys have increased bicarbonate (HCO₃⁻) levels as a compensatory response to offset the respiratory acidosis, which is why the pH has been brought back to the low end of the normal range. This indicates full compensation.

Imagine CO₂ as "exhaust" that needs to be vented out of the body to keep the pH balanced. In respiratory acidosis, too much "exhaust" builds up. The kidneys help balance this by producing more "buffers" (bicarbonate) to neutralize the acidity, keeping the pH just within the normal range.

Nurse Taylor should focus on interventions to manage Noah’s respiratory status and prevent further CO₂ retention.

• Administer bronchodilators and corticosteroids as prescribed to help open Noah’s airways and reduce inflammation, which can improve ventilation and CO₂ clearance.
• Monitor oxygen saturation and provide supplemental oxygen as ordered, ensuring careful monitoring to avoid further respiratory depression.
• Observe for signs of respiratory fatigue or worsening distress, as Noah may be at risk for acute respiratory failure due to his compromised respiratory status.
• Educate Noah’s mother on managing asthma triggers and signs of respiratory distress to help prevent exacerbations in the future.
• Assess for side effects of medications, particularly if Noah is receiving corticosteroids or bronchodilators, which can cause tremors and behavioral changes as noted by his mother.

✘Incorrect answer options:

Respiratory Acidosis, Uncompensated: This is incorrect because the kidneys have compensated for the elevated PaCO₂ by increasing the bicarbonate level. If it were uncompensated, the HCO₃⁻ would be within the normal range and the pH would remain below 7.35.

Metabolic Alkalosis, Partially Compensated: This is incorrect because the primary disturbance is respiratory, not metabolic. Metabolic alkalosis would present with an elevated HCO₃⁻ and a high pH, neither of which are consistent with the findings here.

Respiratory Alkalosis, Fully Compensated: This is incorrect because the elevated PaCO₂ and the near-normal pH indicate a respiratory acidosis, not alkalosis. Respiratory alkalosis would be indicated by a low PaCO₂ (hypocapnia), which is not present here.

EXPLANATION

✔Correct answer:

Immediately assess the client, focusing on neurological and cardiovascular status. Given the information provided by the LPN/LVN, Nurse Emily’s priority action should be to personally assess the client, with an emphasis on neurological and cardiovascular assessment. A sudden drop in blood pressure and heart rate, combined with unilateral facial twitching, could be indicative of serious complications, such as electrolyte imbalances (particularly hypocalcemia), neurological events (like a stroke or seizure), or other critical conditions. Direct assessment by the RN is essential to gather accurate data, perform focused evaluations, and determine the need for further intervention or immediate treatment.

Hypocalcemia is one possible cause that may explain both hypotension and facial twitching (which could indicate Chvostek’s sign, a classic sign of low calcium levels). Low calcium can cause neuromuscular excitability, leading to twitching, spasms, and in severe cases, cardiac complications like hypotension and bradycardia. Additionally, any sudden neurological change, such as facial twitching, requires prompt assessment to rule out other possible causes like stroke or seizure activity.

Imagine hearing an unusual noise coming from your car engine. Rather than guessing what’s wrong, you’d immediately inspect the engine to identify the issue. Similarly, the RN should assess the client directly to understand what’s happening rather than acting on assumptions.

Following the assessment, Nurse Emily can implement or request interventions based on the findings, and she should communicate critical changes to the healthcare provider if needed.

• Perform a neurological assessment, including checking for additional signs of hypocalcemia (e.g., Trousseau's sign) or other neurological deficits.
• Conduct a cardiovascular assessment, focusing on blood pressure, heart rate, and rhythm, as well as any signs of perfusion issues.
• Notify the healthcare provider of the findings, especially if hypocalcemia or other critical conditions are suspected.
• Anticipate orders for lab work to check electrolyte levels, especially calcium, as well as other relevant tests like ECG if cardiac instability is suspected.
• Document all findings and actions taken, including the initial report from the LPN/LVN and Emily’s subsequent assessment results.

✘Incorrect answer options:

Ask the LPN/LVN to administer antihypertensive medication to stabilize blood pressure. Administering antihypertensive medication is contraindicated here. The client’s blood pressure has dropped, so further lowering it would exacerbate hypotension. The RN should first assess the underlying cause of the hypotension before considering any medication adjustments.

Instruct the LPN/LVN to give the patient a mild sedative for facial twitching. Facial twitching may indicate an underlying electrolyte imbalance or neurological issue, not simply anxiety or agitation. Sedation would not address the root cause and may mask important symptoms. The priority is to assess and treat the underlying issue rather than suppress the symptom.

Request that the dietary department send a high-sodium meal to raise the patient's blood pressure. While sodium can influence blood pressure, this is not an appropriate or immediate intervention for acute hypotension with associated symptoms of facial twitching. Addressing the cause of the low blood pressure and twitching through assessment and possibly other interventions is more critical than dietary changes at this moment.

EXPLANATION

✔Correct answer:

Offer frequent oral care, approximately every 3-4 hours. In cases of hypernatremia, patients may experience dry mouth and mucous membranes, leading to discomfort. Frequent oral care helps maintain moisture in the mouth and provides comfort to the patient, which is especially important given the fluid restrictions and imbalances that often accompany acute renal failure. This task is appropriate to delegate to a nursing assistant because it is a non-invasive, routine task that does not require clinical judgment. It also aligns well with the skills and responsibilities of a nursing assistant, who can provide supportive care to enhance the patient’s comfort.

According to the principles of delegation, tasks that do not require critical assessment, decision-making, or specialized nursing skills can be safely delegated to a nursing assistant. Oral care is a supportive task aimed at comfort, which makes it appropriate for delegation in this context.

Think of the nursing assistant’s role like a caregiver who helps keep a person's lips and mouth comfortable and moist, especially when they’re unable to drink enough fluids. This simple care can improve comfort without needing complex medical skills.

Although the nursing assistant can perform the task of oral care, Nurse Alex should monitor the patient’s overall condition and provide instructions on what to report back.

• Instruct the nursing assistant to provide gentle oral care with a moist sponge or swab every 3-4 hours, as well as after meals.
• Ask the nursing assistant to notify the nurse if they notice any signs of worsening dryness, cracked lips, or lesions in the oral cavity.
• Ensure that the nursing assistant avoids using alcohol-based mouthwashes, which can further dry the oral mucosa.
• Encourage communication between the nursing assistant and nurse to promptly address any discomfort experienced by the patient.

✘Incorrect answer options:

Administer 0.45% saline via IV line. Administering intravenous fluids, such as 0.45% saline, is a clinical task that requires assessment, knowledge of IV therapy, and an understanding of fluid balance. This task requires clinical decision-making and is within the RN’s scope of practice, not that of a nursing assistant.

Evaluate daily weight measurements for any trends. Although a nursing assistant can take daily weights, evaluating trends requires clinical interpretation, which is the responsibility of the RN. Nurse Alex, as the RN, should be the one to assess and analyze daily weights for trends in fluid balance, especially in a patient with acute renal failure and hypernatremia.

Observe the client for signs indicative of dehydration. Observation for clinical signs of dehydration requires an understanding of the symptoms associated with fluid imbalance, including dry mucous membranes, low blood pressure, and altered mental status. Assessing and interpreting these symptoms requires critical thinking and clinical judgment, which are within the RN’s scope of practice and should not be delegated to a nursing assistant.

EXPLANATION

✔Correct answer:

7.40. The standard reference range for blood pH in a healthy adult is 7.35 to 7.45, with an ideal midpoint of 7.40. This range represents the normal acid-base balance in the body, where the blood pH is slightly alkaline. Any deviation below 7.35 indicates acidosis, and any deviation above 7.45 indicates alkalosis.

In this case:

• The patient's pH is 7.2, which is below the normal range, indicating acidosis.
• Other ABG values (PaCO₂ of 66 mm Hg and HCO₃ of 27 mmol/L) suggest that the acidosis is primarily respiratory in origin, as indicated by the elevated PaCO₂, a hallmark of respiratory acidosis due to CO₂ retention.

Understanding the normal pH range is crucial for interpreting ABGs and identifying acid-base imbalances accurately. Maintaining a pH of 7.40 (the midpoint of the normal range) is essential for optimal enzyme function, metabolic reactions, and overall cellular function in the body.

✘Incorrect answer options:

7.20: This is incorrect because a pH of 7.20 is below the normal range and would indicate acidosis. It is not within the standard reference range.

7.30: This is incorrect because, while a pH of 7.30 is close to the normal range, it is on the lower side and would suggest a slightly acidotic state.

7.50: This is incorrect because a pH of 7.50 is above the normal range and would indicate alkalosis. It is not within the standard reference range for blood pH.

EXPLANATION

✔Correct answer:

Potassium levels. The presence of noticeable U waves on an ECG is often associated with hypokalemia, or low potassium levels. U waves are abnormal deflections that appear after the T wave and are more pronounced when potassium levels are low. Hypokalemia can affect the electrical activity of the heart, leading to various ECG changes, including flattened T waves, ST segment depression, and prominent U waves. Since low potassium can increase the risk of dangerous arrhythmias, checking potassium levels immediately is essential for appropriate intervention.

Potassium plays a critical role in cardiac muscle function and electrical conductivity. Low potassium levels disrupt the normal repolarization process, causing alterations in the ECG waveform, such as the appearance of U waves. If left untreated, hypokalemia can lead to serious arrhythmias, including ventricular tachycardia and fibrillation, which can be life-threatening.

Think of potassium as a key ingredient that keeps the heart's rhythm steady, like the right amount of oil needed in an engine. Without enough oil, the engine runs rough and could break down. Similarly, low potassium disrupts the heart’s electrical function, causing the rhythm to appear irregular with U waves on the ECG.

Once hypokalemia is suspected based on ECG findings, the nurse should promptly assess and take steps to address the patient’s potassium level.

• Obtain a stat lab order for serum potassium levels to confirm hypokalemia.
• Collaborate with the healthcare provider to initiate potassium supplementation if necessary, based on lab results.
• Monitor the ECG continuously for any additional arrhythmias or significant changes.
• Educate the patient on symptoms of hypokalemia, such as muscle weakness or cramps, and when to notify nursing staff.
• Assess the patient’s dietary intake and medications, as some diuretics (e.g., furosemide) and inadequate dietary intake may contribute to low potassium levels.

✘Incorrect answer options:

Magnesium levels. While magnesium is also an important electrolyte for cardiac function, it primarily affects the QT interval on an ECG rather than causing U waves. Hypomagnesemia can lead to QT prolongation and Torsades de Pointes, a specific type of ventricular tachycardia. Therefore, magnesium levels are not the primary lab value to check when U waves are observed.

Calcium levels. Abnormal calcium levels can affect the QT interval and lead to other changes in the ECG, but they are not typically associated with the presence of U waves. Hypercalcemia may shorten the QT interval, while hypocalcemia may prolong it, but neither is known to produce U waves.

Sodium levels. Sodium is crucial for overall fluid balance and neuronal function, but it does not have a direct effect on the formation of U waves on an ECG. While extreme sodium imbalances can cause neurologic and muscular symptoms, they are not directly linked to the ECG changes seen in hypokalemia.

EXPLANATION

✔Correct answer:

Elevated pH and decreased PCO₂. At high altitudes, such as 5,000 meters (about 16,400 feet) above sea level, the oxygen level in the atmosphere is significantly lower than at sea level. This low oxygen environment can lead to hypoxemia (low blood oxygen levels). In response, the body increases the respiratory rate to take in more oxygen, a process known as hyperventilation.

Effects of Hyperventilation at High Altitudes:

• Hyperventilation causes an increased exhalation of CO₂, which is an acidic component in the blood.
• As CO₂ levels drop, this leads to a decrease in arterial PCO₂ (partial pressure of CO₂).
• The reduction in CO₂ (an acid) causes the blood pH to rise, leading to respiratory alkalosis (elevated pH).

Anticipated ABG Changes:

• Decreased PCO₂: Due to hyperventilation, CO₂ is “blown off” more quickly, resulting in a lower-than-normal PCO₂.
• Elevated pH: As CO₂ decreases, the blood becomes more alkaline, leading to an increase in pH.

In summary, the adventurer at high altitude would experience elevated pH and decreased PCO₂ due to the body’s compensatory response to low oxygen levels.

Think of CO₂ as an “acidic gas” in the blood. At high altitudes, hyperventilation reduces this “acidic gas,” leading to a higher (more alkaline) blood pH.

If this situation were to occur in a clinical context, a nurse might take the following steps to address altitude-related respiratory alkalosis.

• Encourage the individual to pace themselves and avoid rapid ascent to prevent severe altitude sickness.
• Consider the use of acetazolamide (a carbonic anhydrase inhibitor) if prescribed, as it can help the body acclimate by promoting renal excretion of bicarbonate, thus counteracting alkalosis.
• Encourage adequate hydration to support overall physiological function and acclimatization at high altitude.
• Educate the individual on recognizing symptoms of altitude sickness, such as headaches, dizziness, nausea, and shortness of breath.

✘Incorrect answer options:

Both pH and PCO₂ will be lower than normal.: This is incorrect because, while high altitude does lead to low PCO₂ due to hyperventilation, the pH would actually be elevated (not lowered) as a result of respiratory alkalosis.

Both pH and PCO₂ will be higher than normal due to physical exertion.: This is incorrect because, although physical exertion could potentially increase PCO₂, the primary response at high altitude is hyperventilation, which reduces PCO₂ and raises pH.

Decreased pH and elevated PCO₂.: This is incorrect because decreased pH and elevated PCO₂ are characteristic of respiratory acidosis, which occurs due to hypoventilation (not hyperventilation). At high altitudes, the adventurer would likely experience respiratory alkalosis with decreased PCO₂ and increased pH.

EXPLANATION

✔Correct answer:

"The low phosphorus levels are causing skeletal muscle weakness, affecting her ADLs." Chronic low phosphorus levels (hypophosphatemia) can lead to skeletal muscle weakness, which directly impacts a client’s ability to perform activities of daily living (ADLs). Phosphorus is a key electrolyte necessary for energy production (as part of ATP, adenosine triphosphate) and muscle function. When phosphorus levels are low, cells cannot efficiently produce energy, leading to muscle weakness and fatigue. This weakness can make it challenging for the client to perform basic self-care tasks, explaining the need for additional assistance.

Phosphorus is essential for cellular energy production because it is a primary component of ATP, the body's main energy carrier. In cases of hypophosphatemia, ATP production decreases, leading to reduced energy in muscle cells and weakened muscle contraction. Over time, this deficiency can result in skeletal muscle weakness, particularly in chronic cases, affecting mobility and self-care ability.

Think of phosphorus as the fuel that powers your muscles, like gasoline for a car engine. Without enough fuel, the car can't perform well. Similarly, without enough phosphorus, muscles can't function properly, resulting in weakness and difficulty with physical tasks.

It is important for Nurse Liam to ensure the client receives adequate phosphorus through diet and, if prescribed, supplements, while also providing appropriate assistance with ADLs to prevent fatigue and injury.

• Encourage phosphorus-rich foods in the client’s diet, such as dairy, meat, fish, and whole grains, if appropriate.
• Collaborate with the healthcare provider regarding phosphorus supplementation if dietary intake alone is insufficient.
• Monitor for symptoms of hypophosphatemia, such as muscle weakness, fatigue, respiratory difficulty, and neurological changes.
• Coordinate with the nursing assistant to provide support with ADLs to prevent the client from becoming overly fatigued.
• Educate the client and their family on the importance of phosphorus in muscle function and how to support phosphorus levels through nutrition and follow-up care.

✘Incorrect answer options:

"The client will become more independent when her phosphorus levels normalize." While it is possible that the client’s ADL performance might improve with normalized phosphorus levels, this response does not fully explain why low phosphorus affects muscle strength and ADL capability. It lacks educational value for the nursing assistant in understanding the specific effects of hypophosphatemia.

"The client is simply fatigued due to inadequate rest." This response is inaccurate because it attributes the client’s need for ADL assistance to lack of rest rather than addressing the actual cause—low phosphorus levels leading to muscle weakness. This answer overlooks the physiological impact of hypophosphatemia on muscle strength.

"The client's low phosphorus levels are likely a result of malnutrition." While malnutrition can lead to hypophosphatemia, this response does not directly answer the nursing assistant’s question about why the client requires extra help with ADLs. The question is about the effects of low phosphorus, not its cause, so this response is off-topic and may lead to confusion.

EXPLANATION

✔Correct answer:

Respiratory Alkalosis. The employee is most at risk for respiratory alkalosis due to his rapid respiratory rate of 34 breaths per minute, which indicates hyperventilation. Hyperventilation causes an excessive "blow-off" of carbon dioxide (CO₂), reducing the CO₂ levels in the blood. CO₂ is an acidic component, so when CO₂ levels drop too low, the blood pH rises, leading to alkalosis.

Clinical Context:

• The symptoms of dizziness, tingling in the fingertips (paresthesia), and emotional distress are classic signs of respiratory alkalosis, which can result from hyperventilation.
• Hyperventilation is often triggered by stress, anxiety, or emotional distress, all of which can lead to rapid breathing as the body tries to cope with heightened stress responses.
• If left untreated, respiratory alkalosis can lead to further symptoms such as muscle cramps, confusion, and potentially fainting due to decreased cerebral blood flow.

Pathophysiology:

• CO₂ is a natural acid in the body. When a person hyperventilates, they exhale too much CO₂, leading to a decrease in blood CO₂ levels.
• This reduction in CO₂ leads to a rise in blood pH, causing an alkalotic state (respiratory alkalosis).

Imagine CO₂ as the "acidic brake" for blood pH. Rapid breathing releases this acidic CO₂ too quickly, leading to an increase in pH and causing alkalosis. The tingling and dizziness are like the body’s “check engine” lights, indicating that the balance is off.

If the individual were brought to a healthcare setting, nursing interventions should focus on slowing the respiratory rate and managing symptoms of hyperventilation and emotional distress.

• Encourage slow, controlled breathing to help retain CO₂ and reduce alkalosis. Breathing into a paper bag can be helpful in some cases to rebreathe CO₂ (but should be used with caution).
• Provide a calm and reassuring environment to reduce anxiety and help slow breathing naturally.
• Monitor the individual for other symptoms of respiratory alkalosis, such as muscle cramps or further confusion.
• Educate the individual on relaxation techniques, such as deep breathing exercises, to manage anxiety and prevent hyperventilation episodes in the future.

✘Incorrect answer options:

Metabolic Alkalosis: This is incorrect because metabolic alkalosis is usually caused by factors such as excessive vomiting, diuretic use, or bicarbonate ingestion, which increase bicarbonate levels or decrease acid levels in the body. This individual’s symptoms are due to hyperventilation, not a metabolic disturbance.

Metabolic Acidosis: This is incorrect because metabolic acidosis is typically caused by an accumulation of acids (such as in diabetic ketoacidosis or lactic acidosis) or a loss of bicarbonate (such as in diarrhea). The symptoms of hyperventilation, tingling, and dizziness do not align with metabolic acidosis.

Respiratory Acidosis: This is incorrect because respiratory acidosis is caused by hypoventilation, which leads to CO₂ retention and a decrease in pH (acidosis). In this case, the individual is hyperventilating, which would lead to CO₂ loss and an increase in pH (alkalosis), not acidosis.

EXPLANATION

✔Correct answer:

A 72-year-old client with COPD, whose arterial blood gases (ABGs) are normal but is dependent on a ventilator. The 72-year-old client with COPD who is ventilator-dependent but has stable and normal ABGs is the most appropriate assignment for a nurse from the step-down unit. This patient is stable in terms of blood gas levels and is receiving ongoing ventilatory support without any acute respiratory complications. While the client is ventilator-dependent, the fact that their ABGs are normal indicates that they are not in an acute respiratory crisis, making this a relatively stable ICU patient suitable for a nurse who does not typically work in the ICU.

Step-down unit nurses are accustomed to caring for patients who require a higher level of monitoring than a general medical-surgical unit but are not as critically unstable as typical ICU patients. A stable ventilator-dependent patient with controlled ABGs aligns well with their skill set, making this assignment manageable and safe.

Think of this assignment like having an experienced driver handle a car with a specific setting they’re familiar with, rather than handling a car with an unknown problem. The stable ventilator-dependent client has predictable needs, similar to the patients the nurse typically cares for in a step-down unit.

For this client, the nurse from the step-down unit will focus on routine ventilator monitoring, patient comfort, and prevention of complications related to ventilator dependency.

• Monitor vital signs and respiratory status regularly to ensure continued stability.
• Perform routine ventilator care and maintain airway patency, including suctioning as needed.
• Assess for signs of ventilator-associated pneumonia or other complications, which is particularly important in COPD patients.
• Communicate any changes in respiratory status or ABG results to the ICU team promptly.
• Support weaning protocols, if appropriate, and ensure patient comfort and positioning to facilitate respiratory function.

✘Incorrect answer options:

A 68-year-old client hooked up to a ventilator, suffering from acute respiratory failure accompanied by respiratory acidosis. This client is experiencing acute respiratory failure with respiratory acidosis, which indicates a critical, unstable condition requiring complex management and frequent adjustments to ventilatory support. This level of acuity is better suited to an experienced ICU nurse rather than a step-down nurse.

A 38-year-old client on a ventilator due to a narcotic overdose, presenting with respiratory alkalosis. While this client may improve relatively quickly with proper management, respiratory alkalosis and recent overdose present significant risks that require close ICU monitoring and frequent adjustments in care. A nurse familiar with critical ICU protocols would be more appropriate to handle the complexities of ventilator management and monitor for potential complications, such as re-sedation or further acid-base imbalances.

A freshly admitted 56-year-old client diagnosed with diabetic ketoacidosis (DKA), currently on an insulin drip. DKA is a critical condition requiring meticulous management, including continuous insulin infusion, frequent monitoring of blood glucose and electrolytes, and close observation for complications such as cerebral edema. This patient’s needs are better suited to an ICU nurse experienced in managing critical metabolic disturbances and capable of making rapid adjustments based on lab values and clinical assessment.

EXPLANATION

✔Correct answer:

Metabolic Alkalosis. The arterial blood gas (ABG) values indicate metabolic alkalosis. Let’s analyze each component to understand why this is the correct interpretation.

1. pH 7.55: This is above the normal range of 7.35-7.45, indicating alkalosis.
2. PCO₂ 52 mm Hg: This is slightly above the normal range of 35-45 mm Hg, suggesting that the respiratory system is attempting to compensate by retaining CO₂. By increasing CO₂ levels, the body is trying to counteract the alkalotic state and lower the pH.
3. HCO₃⁻ 40 mmol/L: This is significantly elevated above the normal range of 22-26 mmol/L, which indicates that the primary cause of the alkalosis is metabolic (an excess of bicarbonate).

Clinical Context:

• The aspiration of upper gastrointestinal (GI) tract contents suggests the removal of gastric acid, which can lead to metabolic alkalosis. This happens because the loss of gastric acid (hydrochloric acid) leaves the body with relatively more bicarbonate, increasing blood pH and leading to an alkalotic state.
• The elevated PCO₂ shows that the respiratory system is trying to compensate for the high pH by hypoventilating (slowing down breathing) to retain CO₂, which is acidic and helps lower the pH.

The ABG values and clinical context (aspiration of GI contents) confirm metabolic alkalosis with partial respiratory compensation. The elevated bicarbonate level is the primary disturbance, and the slightly elevated PCO₂ indicates an attempt at compensating by the respiratory system.

Imagine the stomach acid as a balancing weight that keeps the body's pH in check. When gastric acid is lost (such as through aspiration), there is less acid in the system, and the body's pH tilts toward alkalosis. The body then tries to balance this by slowing breathing to keep CO₂, which is acidic, but full compensation may not be achieved immediately.

Nurse interventions should focus on monitoring the patient for symptoms of metabolic alkalosis and preventing further imbalances.

• Monitor electrolyte levels closely, especially potassium and chloride, as metabolic alkalosis is often associated with hypokalemia and hypochloremia.
• Assess for signs of metabolic alkalosis, such as muscle cramps, weakness, confusion, or arrhythmias, and report any abnormalities.
• Provide appropriate fluid therapy as ordered to help correct any dehydration and electrolyte imbalances.
• Document the ABG results and closely monitor for any changes in respiratory rate or depth, as the body may adjust ventilation to compensate further.
• Educate the patient and family on potential causes of metabolic alkalosis, especially if gastric drainage or aspiration may be needed in the future.

✘Incorrect answer options:

Respiratory Alkalosis: This is incorrect because respiratory alkalosis would be indicated by a low PCO₂ (below 35 mm Hg), resulting from hyperventilation. Here, the PCO₂ is elevated, which indicates that the body is attempting to compensate for a primary metabolic disturbance.

Respiratory Acidosis: This is incorrect because respiratory acidosis would present with a low pH (acidic) and an elevated PCO₂, indicating CO₂ retention due to hypoventilation. Although the PCO₂ is slightly elevated here, it is compensatory, and the primary issue is metabolic alkalosis, as shown by the elevated HCO₃⁻.

Metabolic Acidosis: This is incorrect because metabolic acidosis would present with a low pH (acidic) and a low HCO₃⁻ level. In this case, the pH is high, and the HCO₃⁻ is elevated, indicating an alkalotic state rather than acidosis.

EXPLANATION

✔Correct answer:

Monitor for hyponatremia. In patients with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH), the primary electrolyte imbalance to monitor is hyponatremia (low sodium levels). SIADH leads to excessive release of antidiuretic hormone (ADH), which causes the kidneys to retain water instead of excreting it. This water retention dilutes the sodium in the bloodstream, leading to hyponatremia. Hyponatremia is a critical concern in SIADH because it can result in neurological symptoms such as confusion, seizures, and even coma if left untreated.

ADH is responsible for promoting water reabsorption in the kidneys, which is meant to help regulate fluid balance. In SIADH, the excess ADH causes an abnormal increase in water reabsorption, leading to a dilutional effect on serum sodium. This dilution lowers sodium concentration without changing the total amount of sodium in the body, resulting in hyponatremia. Monitoring for signs and symptoms of hyponatremia, such as headache, nausea, muscle cramps, and mental status changes, is essential in patients with SIADH.

Imagine adding extra water to a soup without increasing the salt. The salt concentration becomes diluted, and the soup tastes less salty. Similarly, in SIADH, excessive water dilutes the sodium in the bloodstream, leading to low sodium levels or hyponatremia.

When managing a patient with SIADH, the nurse should implement strategies to monitor and address hyponatremia to prevent complications.

• Monitor serum sodium levels regularly to assess the severity of hyponatremia and guide treatment.
• Assess for neurological changes, such as confusion, irritability, or seizures, which are signs of worsening hyponatremia.
• Restrict fluid intake as prescribed to help concentrate serum sodium levels and prevent further dilution.
• Administer hypertonic saline (e.g., 3% saline) as ordered for severe hyponatremia, with close monitoring to avoid rapid sodium correction.
• Educate the patient and family about fluid restrictions and the importance of adhering to them to manage hyponatremia.

✘Incorrect answer options:

Assess for hypernatremia. Hypernatremia (high sodium levels) is not a typical concern in SIADH because the condition leads to water retention, which dilutes sodium rather than concentrating it. The hallmark electrolyte disturbance in SIADH is hyponatremia, not hypernatremia.

Keep an eye on hyperkalemia. SIADH primarily affects water and sodium balance, not potassium levels. Hyperkalemia (high potassium levels) is not a usual complication of SIADH, so this is not a primary electrolyte imbalance to monitor in this condition.

Be cautious of hypokalemia. While hypokalemia (low potassium levels) can occur in various conditions, it is not directly associated with SIADH. SIADH affects sodium levels due to water retention and dilutional hyponatremia, without a significant impact on potassium.

EXPLANATION

✔Correct answer:

Offer the client sips of water or ice chips frequently. In the case of a client with dehydration, the best task for Nurse Emily to delegate to the LPN/LVN is to offer the client sips of water or ice chips frequently. This intervention directly addresses the client’s dehydration by helping to increase their fluid intake in small, manageable amounts. It’s a straightforward task that does not require advanced clinical judgment, making it an appropriate task to delegate to an LPN/LVN.

Dehydration leads to dry mucous membranes, increased thirst, and other systemic symptoms. Offering sips of water or ice chips is a basic intervention that can help to relieve oral dryness and prevent further complications. It’s also a practical way to increase the client’s comfort and contribute to gradual rehydration. Since the LPN/LVN is capable of providing basic client care, this task is within their scope of practice and does not require the higher-level assessment skills of an RN.

Think of dehydration as a dry sponge that needs water to become soft and flexible again. Offering frequent sips of water or ice chips is like adding small amounts of water to the sponge over time, gradually rehydrating it to its normal state.

In cases of dehydration, frequent small intakes of fluid can be more effective and better tolerated than trying to drink large amounts at once. When assigning tasks like these, it’s important to consider the LPN/LVN’s scope of practice and to ensure that hydration interventions are monitored for effectiveness.

• Encourage the client to take small sips or ice chips frequently rather than large amounts at once, which can help prevent nausea.
• Document the fluid intake as part of the overall hydration plan to monitor progress in alleviating dehydration.
• Continue to assess the client’s overall hydration status, such as checking for skin turgor and urine output, to evaluate the effectiveness of the intervention.

✘Incorrect answer options:

Assess the client's oral mucosa for signs of dryness or lesions. Assessment is within the scope of an RN’s role, as it involves evaluating the client’s condition and making clinical judgments. This task should not be delegated to an LPN/LVN, as it requires a higher level of critical thinking.

Teach the client how to perform frequent oral rinsing. Teaching clients requires an understanding of educational strategies and is typically the responsibility of the RN, particularly in complex cases. While LPNs/LVNs may reinforce teaching, the initial education, especially in situations related to clinical conditions like dehydration, is best performed by the RN.

Develop a schedule for oral hygiene care throughout the day. Developing a schedule involves planning and prioritizing client care, which falls under the RN's role. The RN should establish care schedules based on the client’s overall needs, while the LPN/LVN can assist in implementing those schedules.

EXPLANATION

✔Correct answer:

A history of chronic renal insufficiency. Chronic renal insufficiency is a significant risk factor for acid-base imbalances, particularly metabolic acidosis. The kidneys play a critical role in maintaining acid-base balance by excreting hydrogen ions and reabsorbing bicarbonate. When kidney function is impaired, the kidneys are less able to excrete acids effectively and may fail to reabsorb enough bicarbonate, leading to a buildup of acids in the blood. This can result in metabolic acidosis, a common complication in clients with chronic kidney disease or renal insufficiency. Nurse Victoria should be alert to this risk and monitor for signs of acid-base disturbances.

In chronic renal insufficiency, reduced glomerular filtration rate (GFR) impairs the kidneys' ability to regulate the body's acid-base balance. As a result, metabolic waste products and acids (such as hydrogen ions) accumulate in the bloodstream, leading to a decrease in blood pH and bicarbonate levels. Monitoring renal function and acid-base status in patients with chronic renal insufficiency is essential to prevent complications and guide management.

Think of the kidneys like a filter that prevents waste from building up in water. If the filter gets clogged or works poorly (as in chronic renal insufficiency), acids can accumulate, making the water (or blood) more acidic over time.

For a client with chronic renal insufficiency, Nurse Victoria should monitor acid-base balance and renal function closely, especially if there are signs of worsening renal function.

• Assess the client’s blood pH, bicarbonate (HCO₃⁻), and electrolyte levels to identify any acid-base imbalances, especially metabolic acidosis.
• Monitor renal function indicators, such as blood urea nitrogen (BUN) and creatinine, as these values can provide insight into kidney function.
• Evaluate for symptoms of acidosis, including fatigue, confusion, tachypnea, and lethargy, which may signal worsening acid-base imbalance.
• Educate the client on dietary adjustments (e.g., limiting protein intake) to reduce acid load on the kidneys, if advised by a dietitian or physician.
• Collaborate with the healthcare team to initiate treatments, such as bicarbonate supplementation, if metabolic acidosis is confirmed.

✘Incorrect answer options:

Intermittent consumption of antacids. While excessive or chronic use of antacids, especially those containing bicarbonate, can lead to metabolic alkalosis, intermittent use is less likely to cause significant acid-base imbalances. Occasional antacid use typically does not place a client at high risk, especially if renal function is normal and there is no other history of acid-base disturbances.

Previous myocardial infarction one year prior. Although a history of myocardial infarction can indicate cardiovascular risks, it is not directly associated with a high risk for acid-base imbalances. Acute cardiac events may lead to temporary respiratory alkalosis or acidosis due to stress, hypoxia, or altered ventilation, but a past myocardial infarction from a year ago does not pose an ongoing risk for acid-base imbalance.

Experiencing shortness of breath only during intense physical exertion. Shortness of breath during intense exercise is usually related to the body's increased oxygen demands and does not suggest an underlying acid-base imbalance. Unless shortness of breath is associated with chronic respiratory issues (such as COPD or heart failure), it is unlikely to pose a risk for acid-base imbalances in the context of normal physical exertion.

EXPLANATION

✔Correct answer:

"The client could be experiencing metabolic alkalosis due to NG suctioning, and the increased breathing rate is a compensatory action." Nasogastric (NG) suctioning removes gastric contents, including hydrochloric acid (HCl). When a client loses large amounts of gastric acid, it can lead to metabolic alkalosis due to a decrease in hydrogen ions in the blood, causing the pH to rise. In metabolic alkalosis, the body compensates by attempting to increase carbon dioxide (CO₂) levels, which is done by slowing the respiratory rate. However, in some cases, increased respiratory rate can occur as an initial compensatory response due to the body’s stress and the need for more oxygen. Over time, compensatory hypoventilation may occur, but early on, metabolic imbalances can sometimes cause a temporary increase in respiratory rate, especially if the client is experiencing discomfort or other stressors.

When metabolic alkalosis occurs, the blood pH rises, and the respiratory system attempts to compensate by retaining CO₂, which is an acid, to balance the high pH. While this usually results in a decrease in respiratory rate (hypoventilation), some clients may initially have increased respiratory rates due to discomfort or other factors. The main point is that metabolic alkalosis is often due to loss of stomach acids (as with NG suctioning), and this can alter breathing patterns.

Think of stomach acid like lemon juice in a recipe that keeps the flavors balanced. Removing too much lemon juice (stomach acid) makes the mixture too bland (alkaline). The body tries to balance this by breathing differently, initially trying to adjust quickly, though it usually slows breathing over time to retain acidity (CO₂).

Nurse Karen should monitor the client’s acid-base balance and educate the student nurse on the effects of NG suctioning on acid-base status.

• Monitor the client's arterial blood gases (ABGs) to assess for metabolic alkalosis and evaluate the effectiveness of compensatory mechanisms.
• Encourage the student nurse to observe for other signs of metabolic alkalosis, such as confusion, muscle twitching, or irritability.
• Consider collaborating with the healthcare provider on adjusting NG suction settings or administering electrolyte replacements to address imbalances.
• Educate the student nurse on the importance of monitoring acid-base balance in clients with NG suction and how the body compensates for changes in pH.
• Provide comfort measures for the client, as discomfort can sometimes exacerbate respiratory rate changes.

✘Incorrect answer options:

"The client might be hyperventilating due to anxiety, so we should keep an eye out for potential respiratory acidosis." While anxiety can increase respiratory rate, respiratory acidosis is not typically a concern in this context. Hyperventilation generally causes respiratory alkalosis (not acidosis), as it lowers CO₂ levels. NG suctioning is more likely to lead to metabolic alkalosis.

"Clients often have a higher respiratory rate when they are uncomfortable from medical procedures like NG tubes." Although discomfort from an NG tube can sometimes increase respiratory rate, this response does not address the underlying issue of metabolic alkalosis due to NG suction. It is important to recognize and educate the student on the connection between NG suctioning and acid-base imbalances.

"Anytime a client develops a respiratory acid-base imbalance, an elevated respiratory rate is beneficial for correcting the issue." This statement is inaccurate and oversimplifies acid-base compensation. An increased respiratory rate does not help in every case of acid-base imbalance. For example, respiratory acidosis requires increased ventilation, while metabolic alkalosis does not benefit from further increases in respiratory rate, as the body often compensates by reducing respiratory rate to retain CO₂.

EXPLANATION

✔Correct answer:

Frequent instances of nausea followed by vomiting. Frequent vomiting is a significant concern in clients undergoing chemotherapy because it can lead to metabolic alkalosis. Vomiting results in the loss of stomach acid (hydrochloric acid), which can cause an increase in blood pH due to the depletion of hydrogen ions. If vomiting is not managed, it can lead to an electrolyte imbalance, dehydration, and alkalosis. For a client on chemotherapy, Nurse William should instruct the nursing assistant to report episodes of nausea and vomiting immediately so that appropriate interventions (such as antiemetic medications and electrolyte monitoring) can be implemented.

Vomiting leads to a loss of gastric acid, which contains hydrogen and chloride ions. The loss of these acidic components causes an increase in blood bicarbonate levels, resulting in metabolic alkalosis. Chemotherapy-induced nausea and vomiting (CINV) is a common side effect and needs to be managed proactively to prevent both dehydration and acid-base imbalances.

Think of stomach acid like the sourness in a recipe. If you keep removing the sour ingredient (acid), the dish becomes unbalanced and too alkaline, just like the blood becomes more alkaline with continued vomiting.

Instructing the nursing assistant to report vomiting episodes promptly allows the nurse to initiate or adjust treatment to manage acid-base balance and prevent complications.

• Administer antiemetics as prescribed to control nausea and reduce vomiting episodes.
• Monitor the client’s electrolyte levels, especially potassium and chloride, as these can be depleted with frequent vomiting.
• Assess for signs of metabolic alkalosis, such as muscle cramps, weakness, or altered mental status, and intervene accordingly.
• Encourage small, frequent meals and hydration to help minimize nausea and maintain electrolyte balance.
• Educate the client and family on the importance of reporting vomiting or signs of dehydration, such as dizziness or decreased urine output.

✘Incorrect answer options:

Noticeable hair loss during the client's morning bath. Hair loss, or alopecia, is a common side effect of chemotherapy but is not directly related to acid-base imbalances. While it may be distressing for the client, it does not require immediate intervention for acid-base management.

Inability to consume all the food served for breakfast. A reduced appetite is common in clients undergoing chemotherapy due to side effects like nausea and taste changes. However, decreased food intake alone does not directly cause an acid-base imbalance. It may contribute to malnutrition or weight loss over time, but it is not an immediate acid-base concern.

Reports of pain experienced during physical activities. Pain during activity is not typically associated with acid-base imbalances and may instead reflect other issues, such as muscle weakness or fatigue. While pain management is important, it is not directly related to acid-base balance and would not need to be reported urgently in this context.

EXPLANATION

✔Correct answer:

Give 40 mg of furosemide (Lasix) via IV push. Administering furosemide (Lasix) via IV push is the most immediate and effective intervention among the options to address the client’s symptoms of Excess Fluid Volume. Furosemide is a loop diuretic that works by increasing renal excretion of sodium, water, and other electrolytes, which helps reduce fluid overload. Given the client's signs—such as pitting edema, moist crackles in the lungs, weight gain, and bounding pulses—administering Lasix can help decrease intravascular and interstitial fluid volume, relieving symptoms of fluid overload and preventing further complications like pulmonary edema.

In cases of fluid overload, the heart struggles to pump effectively due to increased fluid volume, leading to symptoms like edema, weight gain, and moist crackles in the lungs as fluid accumulates. Diuretics like furosemide reduce this volume burden on the heart and lungs by promoting diuresis, thereby reducing extracellular fluid volume and improving symptoms.

Imagine a sponge soaked with water that starts to leak when squeezed. Diuretics like Lasix work similarly by "squeezing" out excess fluid through the kidneys, reducing the overall fluid volume in the body, and thereby relieving the symptoms of fluid overload.

After administering Lasix, the nurse should monitor the patient’s response closely, as diuretics can lead to significant fluid and electrolyte shifts.

• Monitor urine output to assess the effectiveness of the diuretic and ensure that the excess fluid is being excreted.
• Assess for changes in lung sounds, peripheral edema, and weight to evaluate the client’s response to treatment.
• Check blood pressure frequently, as diuresis can cause hypotension in some patients.
• Monitor electrolytes, particularly potassium, as Lasix can cause hypokalemia due to potassium loss in urine.
• Provide the patient with appropriate education regarding signs of electrolyte imbalance and when to alert healthcare providers.

✘Incorrect answer options:

Limit daily fluid intake to 1,500 mL. While restricting fluid intake is an important measure in managing fluid overload, it does not provide immediate relief of the client's current symptoms. Limiting fluids is more of a preventive strategy to prevent further fluid accumulation rather than an immediate intervention to reduce existing excess fluid volume.

Record the patient's weight every morning. Monitoring daily weight is a useful measure for tracking fluid status over time and detecting early signs of fluid retention. However, it is not a direct intervention to reduce the existing fluid volume in the body. Weight monitoring alone will not address the client’s immediate symptoms of fluid overload.

Keep precise records of fluids taken in and expelled. Accurate intake and output (I&O) documentation is essential for managing and monitoring fluid balance. However, similar to daily weight monitoring, it is a tracking measure rather than a direct intervention to actively reduce fluid overload. While important for long-term management, I&O records alone will not immediately relieve the client’s symptoms of fluid overload.

EXPLANATION

✔Correct answer:

Respiratory Acidosis. Jane is most at risk for respiratory acidosis due to her shallow and slow breathing. Respiratory acidosis occurs when there is hypoventilation, which causes an accumulation of carbon dioxide (CO₂) in the blood. CO₂ is acidic, so when the body is unable to expel it effectively, blood pH drops, leading to acidosis. Jane’s shallow breathing following head trauma, combined with the effects of alcohol, puts her at high risk of hypoventilation and thus respiratory acidosis.

Clinical Context:

• Head Injury: A traumatic brain injury can affect the brainstem, which controls the respiratory center. This can lead to impaired respiratory drive, resulting in slow and shallow breathing.
• Alcohol Consumption: Alcohol is a central nervous system depressant, which can further reduce respiratory drive, leading to hypoventilation.
• Shallow Breathing: This directly reduces the amount of CO₂ being exhaled, causing it to build up in the bloodstream and creating an acidic environment.

Without immediate medical intervention, Jane’s CO₂ levels could continue to rise, leading to worsening respiratory acidosis, decreased pH, and potentially life-threatening complications.

Think of CO₂ as "exhaust" that needs to be released with each breath. If breathing slows down or becomes shallow, the "exhaust" builds up, making the blood more acidic (respiratory acidosis).

If Jane is brought to the ER, immediate interventions would focus on maintaining her airway, breathing, and circulation.

• Airway Management: Ensure that her airway is clear and, if necessary, consider intubation to provide adequate ventilation.
• Oxygen Support: Administer supplemental oxygen or ventilatory support to reduce CO₂ buildup and stabilize blood gases.
• Monitor ABGs: Once Jane is stabilized, check arterial blood gases to assess the extent of respiratory acidosis and determine if further interventions are required.
• Assess for Head Trauma: Perform a CT scan or other imaging to assess the extent of her head injury and identify potential intracranial bleeding.
• IV Fluids and Blood Products: If necessary, administer IV fluids and/or blood products to manage hypotension or blood loss from her ear injury.

✘Incorrect answer options:

Metabolic Acidosis: This is incorrect because metabolic acidosis is usually related to conditions that increase the production of acids (like lactic acidosis or diabetic ketoacidosis) or decrease bicarbonate in the blood. In this scenario, the primary issue is hypoventilation, which causes CO₂ buildup rather than a metabolic disturbance.

Metabolic Alkalosis: This is incorrect because metabolic alkalosis is typically caused by excessive bicarbonate levels or the loss of hydrogen ions, such as through prolonged vomiting or excessive use of diuretics. Jane’s situation does not suggest any cause of metabolic alkalosis.

Respiratory Alkalosis: This is incorrect because respiratory alkalosis would result from hyperventilation (rapid breathing), which leads to CO₂ loss and an increase in blood pH. Jane’s breathing is slow and shallow, which would lead to CO₂ retention, not CO₂ loss.

EXPLANATION

✔Correct answer:

"I plan to steer clear of dairy products, broccoli, and spinach in my meals." This statement reveals a misunderstanding about dietary sources of calcium. Dairy products, broccoli, and spinach are all rich sources of calcium and can help maintain adequate calcium levels. Avoiding these foods would deprive the client of natural sources of calcium, potentially leading to a recurrence of hypocalcemia (low calcium levels). It’s important for patients who have had low calcium levels to consume calcium-rich foods, along with supplements if prescribed, to maintain normal calcium levels.

Dietary intake is a key component of managing calcium levels, especially in patients with a history of hypocalcemia. Encouraging a diet rich in calcium-containing foods, such as dairy, green leafy vegetables, and fortified foods, is essential for maintaining calcium balance. Additionally, vitamin D is important for calcium absorption and should be taken as directed to maximize calcium uptake.

Imagine calcium as the building blocks of a wall (your bones and muscles), and dietary sources as regular shipments of bricks. If you stop the shipments (avoid calcium-rich foods), over time, you risk running low on bricks to maintain the wall’s strength.

Nurse Olivia should clarify the importance of including calcium-rich foods in the diet and correct any misconceptions about dietary restrictions related to calcium intake.

• Educate the client on calcium-rich foods that can support their bone health, such as dairy products, leafy greens, and fortified foods.
• Reinforce the role of vitamin D in calcium absorption and the need to follow the healthcare provider’s advice on vitamin D and calcium supplements.
• Advise the client to maintain a balanced diet and follow up with their healthcare provider for regular calcium level monitoring.
• Explain symptoms of hypocalcemia (e.g., muscle twitching, seizures) and the importance of seeking medical attention if these symptoms arise.

✘Incorrect answer options:

"I'll be diligent about taking vitamin D along with my daily calcium." This statement is correct. Vitamin D enhances the absorption of calcium in the intestines, making it a valuable supplement for clients at risk of low calcium levels. This indicates appropriate understanding of the role of vitamin D.

"I'll consume my calcium supplement each morning prior to eating breakfast." This statement is also appropriate. Taking calcium on an empty stomach can enhance its absorption, particularly for calcium carbonate, which is absorbed better in an acidic environment. This statement does not reveal any misunderstanding.

"I'll contact my healthcare provider if I notice muscle twitching or experience seizures." This is an accurate statement. Muscle twitching and seizures are potential symptoms of hypocalcemia, and recognizing these signs as an indication to seek medical help shows good understanding.

EXPLANATION

✔Correct answer:

Supply straws and propose additional fluid intake between meals. This task is appropriate for delegation to a nursing assistant because it involves basic supportive actions that promote fluid intake without requiring clinical judgment or specialized skills. Nursing assistants can effectively assist by offering straws, providing water, and encouraging the client to drink fluids between meals, as this does not require any assessment, planning, or evaluation, which are responsibilities that remain with the registered nurse (RN).

According to the principles of delegation in nursing, tasks that involve routine, non-complex, and predictable aspects of care can be delegated to nursing assistants. Providing straws and reminding or encouraging clients to drink fluids are within a nursing assistant’s scope of practice and help facilitate the client's fluid intake without involving clinical decision-making.

Think of the nursing assistant's role like a friend reminding you to drink water throughout the day. They can offer you a glass of water and encourage you to stay hydrated, but they aren’t responsible for calculating your hydration needs or deciding how much water you should consume.

To support the client’s hydration goals and ensure safe delegation, the nurse should provide clear instructions and monitor the client's overall intake.

• Educate the nursing assistant on the importance of offering fluids frequently and noting any refusals.
• Instruct the nursing assistant to report any signs of dehydration (e.g., dry mouth, concentrated urine) back to the nurse.
• Regularly assess the client’s fluid balance and adjust the care plan as needed based on intake and output.
• Ensure that the nursing assistant understands when and how to encourage fluid intake safely, without forcing fluids.

✘Incorrect answer options:

Formulate a 24-hour strategy to increase the client's fluid intake. Developing a strategy or plan for fluid intake requires clinical assessment and judgment, which are responsibilities that cannot be delegated to a nursing assistant. Creating this plan involves evaluating the client’s overall health, fluid requirements, and specific needs, which fall under the scope of practice for the RN.

Initiate the intravenous fluids as ordered by the physician. Starting or managing intravenous (IV) therapy is a clinical task that requires specialized training, knowledge, and adherence to aseptic techniques. Only licensed personnel, such as RNs or licensed practical nurses (LPNs) with IV certification, should initiate IV fluids. Nursing assistants are not trained or permitted to handle IV therapy.

Educate the client's family on how to assist with maintaining fluid balance. Client and family education is a complex task that requires an understanding of the client’s condition, potential complications, and specific health teaching principles. Only licensed nurses can provide this type of education, as it involves clinical reasoning and adapting information to suit the client’s needs.

EXPLANATION

✔Correct answer:

Metabolic Acidosis, Partially Compensated The ABG results and clinical presentation suggest that Allan is experiencing metabolic acidosis with partial respiratory compensation. Let's break down the findings:

1. pH 7.0: This is well below the normal range of 7.35-7.45, indicating severe acidosis.
2. PaCO₂ 23 mm Hg: This is below the normal range of 35-45 mm Hg, indicating that Allan’s body is trying to compensate for the acidosis by hyperventilating (Kussmaul breathing) to "blow off" CO₂, a mechanism of respiratory compensation.
3. HCO₃⁻ 12 mmol/L: This is significantly lower than the normal range of 22-26 mmol/L, pointing to a metabolic cause of the acidosis due to a substantial loss of bicarbonate or an increase in acid production.

Additional information, such as Allan’s symptoms of dehydration, increased thirst, frequent urination, and recent weight loss, suggests diabetic ketoacidosis (DKA), a common cause of metabolic acidosis in pediatric patients. DKA occurs due to insulin deficiency, leading to fat breakdown and the production of acidic ketone bodies, which lower blood pH.

Interpretation of ABG and Labs:

• The primary issue is metabolic acidosis (low HCO₃⁻), likely due to DKA.
• Partial compensation is evident through the low PaCO₂, indicating that Allan’s body is trying to correct the acidosis through Kussmaul respirations (deep, rapid breathing).
• His other lab values show electrolyte imbalances (e.g., mildly low sodium, elevated potassium) typical of DKA and dehydration.

Think of the blood as a solution that’s too acidic (low pH) because of an overload of acids. The body tries to compensate by breathing heavily to blow off CO₂, which is acidic. However, despite this effort, the pH is still low because the metabolic acidosis is severe.

Managing Allan's metabolic acidosis requires urgent interventions focused on addressing the underlying DKA, rehydrating, and correcting electrolyte imbalances.

• Administer intravenous fluids as ordered to correct dehydration and stabilize electrolytes.
• Begin insulin therapy as prescribed to reduce blood glucose and halt ketone production, helping to resolve acidosis.
• Monitor blood glucose, ABG values, and electrolyte levels frequently to assess treatment efficacy and prevent complications.
• Closely monitor for signs of hypokalemia, as insulin therapy can cause a shift of potassium into cells, lowering serum potassium levels.
• Educate Allan and his family on managing diabetes to prevent future DKA episodes.

✘Incorrect answer options:

Respiratory Acidosis, Partially Compensated: This is incorrect because the primary disturbance is metabolic, not respiratory. The low HCO₃⁻ level indicates metabolic acidosis, and the low PaCO₂ reflects compensation rather than a primary respiratory problem.

Respiratory Acidosis, Uncompensated: This is incorrect because Allan is not in respiratory acidosis. Instead, he is hyperventilating to compensate for metabolic acidosis. In respiratory acidosis, we would expect an elevated PaCO₂, not a low one.

Metabolic Alkalosis, Uncompensated: This is incorrect because Allan's pH is acidic (low) and his HCO₃⁻ is low, which are both consistent with acidosis, not alkalosis.

EXPLANATION

✔Correct answer:

Respiratory Acidosis, Partially Compensated The ABG results indicate respiratory acidosis with partial compensation. Let’s break down the ABG values to interpret this correctly.

1. pH 7.3: This is below the normal range of 7.35-7.45, indicating acidosis.
2. PaCO₂ 68 mm Hg: This is elevated above the normal range of 35-45 mm Hg, which indicates that the acidosis is due to a respiratory cause, as high CO₂ levels indicate hypoventilation or respiratory failure.
3. HCO₃⁻ 28 mmol/L: This is slightly elevated above the normal range of 22-26 mmol/L, suggesting that the kidneys are trying to compensate by retaining bicarbonate to offset the acidosis, though the compensation is not yet complete.
4. PaO₂ 60 mm Hg: This indicates hypoxemia (low oxygen levels), which is common in chronic obstructive pulmonary disease (COPD) exacerbations.

Based on these findings:

• The primary problem is respiratory acidosis due to CO₂ retention (elevated PaCO₂) from COPD and acute respiratory infection, which has worsened his respiratory status.
• The slightly elevated HCO₃⁻ indicates that the kidneys are beginning to compensate by increasing bicarbonate levels, though they have not fully compensated, as the pH remains below 7.35.
• Therefore, this is partially compensated respiratory acidosis.

Think of respiratory acidosis like a room filling with smoke because of poor ventilation. The kidneys are like a fan that tries to clear out the smoke (by retaining bicarbonate), but they’re only partially successful, and the room (blood) is still smoky (acidic).

Nurse interventions should focus on improving ventilation, oxygenation, and monitoring the client's response to treatment.

• Administer supplemental oxygen as prescribed, but carefully monitor for oxygen-induced hypoventilation in COPD patients.
• Encourage or administer bronchodilators to help open the airways and improve CO₂ clearance.
• Monitor ABGs frequently to assess the effectiveness of interventions and ensure the compensation is progressing.
• Position the patient to maximize lung expansion, such as sitting upright, to facilitate better ventilation.
• Provide education and reassurance to the patient and family regarding the management of COPD exacerbations and the importance of adherence to prescribed medications and therapies.

✘Incorrect answer options:

Metabolic Acidosis, Partially Compensated: This is incorrect because the primary disturbance is respiratory, not metabolic. The elevated PaCO₂ points to a respiratory cause of the acidosis, not a metabolic one. In metabolic acidosis, we would expect a low bicarbonate (HCO₃⁻) level, not an elevated one.

Respiratory Acidosis, Uncompensated: This is incorrect because there is evidence of partial compensation. The bicarbonate level is slightly elevated, indicating that the kidneys are beginning to compensate, even though the pH has not returned to normal.

Metabolic Alkalosis, Uncompensated: This is incorrect because the ABG results do not indicate alkalosis. The pH is low (acidosis), and the primary issue is high CO₂, making it a respiratory acidosis, not metabolic alkalosis.

EXPLANATION

✔Correct answer:

Metabolic Alkalosis. Mike’s lab result shows a potassium level of 2.9 mEq/L, which is below the normal range (typically 3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia is often associated with metabolic alkalosis due to the shifts in electrolyte balance and the body's compensatory mechanisms.

How Hypokalemia Leads to Metabolic Alkalosis:

• Electrolyte Shifts: Low potassium levels cause potassium to move out of cells, while hydrogen ions move into cells to maintain electrical neutrality. This intracellular shift of hydrogen ions decreases the hydrogen ion concentration in the blood, increasing blood pH and causing alkalosis.
• Vomiting: Mike has symptoms of nausea and vomiting, which also contribute to metabolic alkalosis. Vomiting causes a loss of gastric acid (hydrochloric acid), leading to an increase in blood bicarbonate and thus raising the blood pH.

Clinical Context:

• Nausea, vomiting, and fatigue are consistent with electrolyte imbalances, particularly hypokalemia, and with acid-base disturbances that arise from both fluid and electrolyte loss.
• Without prompt correction, Mike’s hypokalemia and vomiting may lead to a worsening metabolic alkalosis.

Think of potassium as a “balancer” for acid in the body. When potassium is low, it throws off the acid balance, causing the body to become more alkaline.

Nurse interventions should focus on correcting the hypokalemia and monitoring for symptoms of metabolic alkalosis.

• Administer potassium supplements as prescribed to correct the hypokalemia, either orally or intravenously, depending on severity and urgency.
• Monitor electrolyte levels, especially potassium, chloride, and bicarbonate, to evaluate the effectiveness of treatment and prevent further imbalances.
• Assess for signs of metabolic alkalosis, such as muscle cramps, confusion, and weakness, which may indicate worsening alkalosis.
• Encourage hydration and monitor fluid intake/output, as dehydration can exacerbate electrolyte imbalances.
• Educate the family on recognizing symptoms of electrolyte imbalances and the importance of timely medical attention for future occurrences.

✘Incorrect answer options:

Metabolic Acidosis: This is incorrect because metabolic acidosis is typically associated with high potassium levels (hyperkalemia), not low potassium. In metabolic acidosis, there would be an excess of hydrogen ions, not a deficiency, in the blood.

Respiratory Alkalosis: This is incorrect because respiratory alkalosis is typically caused by hyperventilation, which leads to low PaCO₂, not by low potassium levels. Mike's symptoms do not indicate hyperventilation.

Respiratory Acidosis: This is incorrect because respiratory acidosis is due to CO₂ retention from hypoventilation, resulting in low pH and high CO₂. Mike’s low potassium level and symptoms are more consistent with metabolic alkalosis than with respiratory issues.

EXPLANATION

✔Correct answer:

Metabolic Alkalosis, Uncompensated The ABG results indicate uncompensated metabolic alkalosis. Let’s analyze each component of the ABG values:

1. pH 7.57: This is above the normal range of 7.35-7.45, indicating alkalosis.
2. PaCO₂ 37 mmHg: This is within the normal range of 35-45 mmHg, meaning there is no respiratory compensation. If the body were attempting to compensate for the metabolic alkalosis, we would expect the PaCO₂ to rise as a result of hypoventilation, which would help retain CO₂ (an acid) to lower the pH. Since the PaCO₂ is normal, this indicates a lack of compensation.
3. HCO₃⁻ 30 mEq/L: This is elevated above the normal range of 22-26 mEq/L, indicating that the primary cause of the alkalosis is metabolic in nature, due to an excess of bicarbonate.

Mr. Jefferson's symptoms, particularly the large volume of coffee-ground secretions from the nasogastric tube (NGT), suggest a gastrointestinal (GI) bleed. The coffee-ground appearance indicates that blood has been partially digested, often seen with upper GI bleeding. Additionally, the loss of gastric contents (which contain hydrochloric acid) via NGT drainage can lead to metabolic alkalosis due to the loss of stomach acid. The high pH and elevated bicarbonate confirm metabolic alkalosis as the primary disturbance, with no signs of respiratory compensation.

Think of stomach acid as a balancing weight in the body's acid-base balance. When significant amounts of stomach acid are lost (due to NGT drainage), the balance tips toward alkalosis because there’s too much bicarbonate left relative to acid.

Nurse Sarah should prioritize interventions to manage Mr. Jefferson’s metabolic alkalosis and address the potential GI bleed.

• Closely monitor Mr. Jefferson’s vital signs and mental status for any signs of worsening GI bleed or shock.
• Replace lost electrolytes (such as potassium and chloride) as prescribed, since metabolic alkalosis can worsen with hypokalemia and hypochloremia.
• Prepare for possible interventions to manage the GI bleed, such as blood transfusions, endoscopic evaluation, or surgical consultation.
• Monitor intake and output closely and document the volume and appearance of NGT drainage to track blood loss.
• Educate the patient and family on the importance of notifying healthcare staff if symptoms like increased nausea, pain, or confusion occur.

✘Incorrect answer options:

Metabolic Alkalosis, Partially Compensated: This is incorrect because the PaCO₂ is within the normal range, indicating there is no respiratory compensation. Partial compensation would involve an elevated PaCO₂ due to hypoventilation as the body attempts to balance the high bicarbonate level.

Respiratory Alkalosis, Uncompensated: This is incorrect because the primary disturbance is metabolic, not respiratory. Respiratory alkalosis would present with a low PaCO₂ (below 35 mmHg) and a high pH, which is not the case here. The elevated HCO₃⁻ indicates a metabolic issue.

Metabolic Acidosis, Uncompensated: This is incorrect because the pH indicates alkalosis, not acidosis. Additionally, metabolic acidosis would be associated with a low HCO₃⁻ level, which is not present here.

EXPLANATION

✔Correct answer:

36 mm Hg. The standard reference range for PaCO₂ (partial pressure of carbon dioxide in arterial blood) is typically 35-45 mm Hg. This range is essential for maintaining the body's acid-base balance. PaCO₂ is regulated primarily by the respiratory system, and deviations from this range indicate respiratory changes that may affect acid-base status.

In this case, the patient’s PaCO₂ of 22 mm Hg is below the normal range, indicating compensatory respiratory alkalosis in response to metabolic acidosis. The low bicarbonate (HCO₃⁻ of 14 mmol/L) and the very low pH (7.0) indicate metabolic acidosis as the primary issue. The patient’s body is attempting to compensate by hyperventilating (slow, deep breaths known as Kussmaul respirations) to "blow off" CO₂, which helps to raise the pH slightly, though not fully to normal.

Think of CO₂ as an "acidic gas" that contributes to acidity in the blood. When the body senses too much acid (as in metabolic acidosis), it tries to get rid of CO₂ through deep, rapid breathing to bring the pH closer to normal.

Understanding the normal PaCO₂ range is essential for interpreting ABGs and determining the primary cause of acid-base imbalances in patients.

• Monitor the patient’s respiratory rate and pattern to ensure effective CO₂ clearance.
• Administer IV fluids and electrolyte replacement as prescribed to correct dehydration and electrolyte imbalances, particularly sodium and potassium.
• Assess for other potential causes of metabolic acidosis, such as renal function or ketone bodies if diabetic ketoacidosis is suspected.
• Monitor ABG values frequently to assess the effectiveness of interventions and ensure that the body’s compensatory mechanisms are working appropriately.

✘Incorrect answer options:

22 mm Hg: This is incorrect because 22 mm Hg is below the normal PaCO₂ range (35-45 mm Hg). A PaCO₂ of 22 mm Hg reflects a state of hyperventilation, as the body attempts to compensate for acidosis.

48 mm Hg: This is incorrect because 48 mm Hg is slightly above the normal PaCO₂ range and would indicate hypoventilation, leading to CO₂ retention rather than the compensatory CO₂ reduction seen in metabolic acidosis.

50 mm Hg: This is incorrect because 50 mm Hg is also above the normal range and would indicate respiratory acidosis, where CO₂ is retained due to hypoventilation.

EXPLANATION

✔Correct answer:

Serum magnesium at 0.8 mEq/L. A serum magnesium level of 0.8 mEq/L is significantly below the normal range (usually 1.3-2.1 mEq/L) and requires immediate attention. Hypomagnesemia can have serious effects on the body, particularly on the cardiovascular and neuromuscular systems. Low magnesium levels can lead to increased excitability of muscles and nerves, potentially causing symptoms such as muscle cramps, tremors, and seizures. More critically, hypomagnesemia can also precipitate dangerous cardiac arrhythmias, including ventricular tachycardia and torsades de pointes, which can be life-threatening. Therefore, Nurse Maya should prioritize this lab value to prevent complications associated with low magnesium.

Magnesium plays a crucial role in stabilizing cellular membranes, particularly in cardiac and neuromuscular cells. It helps regulate electrical activity, and low levels can disrupt this regulation, increasing the risk of arrhythmias. In addition, hypomagnesemia can exacerbate other electrolyte imbalances, such as hypokalemia and hypocalcemia, further complicating the patient's condition. Due to these risks, correcting low magnesium levels promptly is essential to ensure the patient's safety.

Think of magnesium as a "shock absorber" in the heart's electrical system. If there isn’t enough magnesium, the heart can start "misfiring," like a car engine running rough without shock absorbers to keep it stable.

Nurse Maya should act promptly to address the hypomagnesemia and monitor the patient for potential complications.

• Notify the healthcare provider immediately about the low magnesium level to obtain orders for supplementation, which may include IV magnesium if the level is critically low.
• Monitor the patient’s ECG for any signs of arrhythmias, especially if they have a history of cardiac issues.
• Assess for symptoms of hypomagnesemia, such as muscle twitching, tremors, or signs of neuromuscular irritability.
• Ensure that other electrolyte levels, especially potassium and calcium, are closely monitored, as they may also need adjustment.
• Educate the patient on the importance of maintaining electrolyte balance, particularly if they are at risk of recurrent low magnesium levels.

✘Incorrect answer options:

Serum sodium at 134 mEq/L. This sodium level is slightly below the normal range (typically 135-145 mEq/L), but mild hyponatremia does not usually require immediate intervention. Mild hyponatremia is often asymptomatic and can be managed by adjusting fluid intake or addressing underlying causes. It does not pose an immediate risk compared to hypomagnesemia.

Serum calcium at 10.6 mg/dL. This calcium level is slightly above the normal range (typically 8.5-10.5 mg/dL) and does not indicate an urgent concern. Mild hypercalcemia is unlikely to cause acute symptoms and generally does not require immediate intervention, especially if there are no associated symptoms like polyuria, abdominal pain, or confusion.

Serum potassium at 5.2 mEq/L. This potassium level is slightly above the normal range (typically 3.5-5.0 mEq/L) and is considered a mild elevation. While hyperkalemia can be dangerous, a level of 5.2 mEq/L is only slightly elevated and does not typically require emergency intervention. It would be prudent to monitor the patient’s potassium level and watch for any symptoms, but it is not as immediately concerning as severe hypomagnesemia.