BSN 366 Acid-Base Imbalances
Questions and Answers
Assessment Related To Electrolyte Balance
Question 1 of 4
Which clinical manifestations should the nurse anticipate when assessing a patient who
is diagnosed with hypernatremia?
Select all that apply.
Hyperactive deep tendon reflexes
Confusion
Thirst
Lethargy
Seizures - ANSWER-Confusion
Thirst
Lethargy
Seizures
Mr. Abdul, a 76-year-old male, has been admitted to the hospital with complaints of
having shortness of breath, headaches and blurred vision, fatigue, and increased
anxiety for the past week. He has begun experiencing tremors in his hand. The tremors
were so severe he was unable to fix his dinner or take his medication. He reports that
he has had increasing trouble keeping his balance when walking and had to borrow a
friend's cane for balance. He has a history of type I diabetes mellitus (DM), treated with
a daily dose of insulin with breakfast. He has smoked one pack of cigarettes per day for
56 years. He was diagnosed with chronic obstructive pulmonary disease (COPD) three
years ago. He has no known drug allergies (NKDA). - ANSWER-Temperature 36.5 °C
(97.7 °F)
Pulse 118 regular
Respirations 32 and labored
BP 160/100 mm Hg
Pulse oximetry 90% on room air
ABG on room air: pH 7.2, PaCO2 60 mm Hg, PaO2 73 mm Hg, HCO3− 25 mEq/L
Urine ketones: +2
Other assessment findings to note include:
Reflexes are +1 bilaterally.
Gait is slow and unsteady, frequently reaches out to wall or furniture to steady self.
Denies pain but is very restless.
Anxious demeanor. Slow to respond to questions. Unsure about answers to some
current events' questions.
Skin is warm, dry, and slightly pale.
Reported sleep quality is good and he says he sleeps about 10 hours at night and takes
two naps during the daytime.
Impaired Gas Exchange
Acute Confusion
,Self-Care Deficit
Question 1 of 12
A patient is admitted with an acid-base imbalance. The patient's current assessment
data includes hypotension and dysrhythmia. Which is the priority nursing diagnosis that
the nurse should include in the plan of care?
Decreased Cardiac Output
Acute Confusion
Impaired Gas Exchange
Fatigue - ANSWER-Decreased Cardiac Output
Acid-base imbalance, coupled with hypotension and dysrhythmia, indicates a priority
nursing diagnosis of Decreased Cardiac Output.
Question 1 of 4
Place the steps the nurse uses to analyze ABGs in the correct order.
1. Evaluate the PaO2 and O2 saturation level.
2. Evaluate the pH to determine if it is acidotic, alkalotic, or within normal range.
3. Evaluate the PaCO2 and HCO3- to determine if the imbalance is respiratory or
metabolic.
4. Evaluate whether or not compensation is occurring. - ANSWER-The steps the nurse
should take to analyze an ABG are to first evaluate the PaO2 and O2 saturation levels
to determine if hypoxemia is occurring. The next step is to evaluate the pH to determine
if it is acidotic, alkalotic, or within normal limits. The third step is to evaluate the PaCO2
and HCO3- to determine if the imbalance is respiratory or metabolic. The final step is to
determine if compensation is occurring.
Question 1 of 4
Which interventions should the nurse implement for a patient who is experiencing
respiratory acidosis?
Select all that apply.
Increase the rate of IV fluid administration
Encourage deep breathing exercises
Monitor breath sounds
Provide emotional support
Administer prescribed narcotic - ANSWER-Encourage deep breathing exercises
The nurse can independently encourage the patient to complete deep breathing
exercises.
Monitor breath sounds
The nurse should monitor the patient's breath sounds due to the current respiratory
status.
Provide emotional support
The nurse should provide emotional support for the patient who is experiencing an acid-
base imbalance.
Question 1 of 4
, Which NOC outcome is appropriate for Mr. Abdul's nursing diagnosis of Acute
Confusion?
Select all that apply.
Cognition
Distorted Thought Self-Control
Information Processing
Memory
Adherence Behavior - ANSWER-Cognition
Distorted Thought Self-Control
Information Processing
Memory
Question 1 of 4
Which questions should the nurse ask when conducting a health history assessment for
a patient who has a potassium imbalance?
Select all that apply.
"Do you have lactose intolerance?"
"Do you take a diuretic, such as furosemide (Lasix)?"
"Are you experiencing swelling in your feet?"
"Do you use a salt substitute on your food?"
"Do you eat canned meats or vegetables often?" - ANSWER-"Do you take a diuretic,
such as furosemide (Lasix)?"
Furosemide is a potassium-wasting diuretic, which can cause hypokalemia.
"Do you use a salt substitute on your food?"
Overuse of potassium-rich salt substitutes by people who have poor renal excretion
may cause hyperkalemia.
Question 1 of 8
A patient presents to the emergency department (ED) with a serum phosphate
concentration of 3.1 mEq/L. Which should the nurse assess this patient for based on
this laboratory value?
Select all that apply.
Tetany
Hyperreflexia
Decreased deep tendon reflexes
Muscle cramps
Shallow respirations - ANSWER-Tetany
A serum phosphate concentration greater than 2.6 mEq/L indicates
hyperphosphatemia. The nurse should assess for tetany, a clinical manifestation of
hypocalcemia caused by hyperphosphatemia.
Hyperreflexia
A serum phosphate concentration greater than 2.6 mEq/L indicates
hyperphosphatemia. The nurse should assess for hyperreflexia, a clinical manifestation
of hypocalcemia caused by hyperphosphatemia.
Questions and Answers
Assessment Related To Electrolyte Balance
Question 1 of 4
Which clinical manifestations should the nurse anticipate when assessing a patient who
is diagnosed with hypernatremia?
Select all that apply.
Hyperactive deep tendon reflexes
Confusion
Thirst
Lethargy
Seizures - ANSWER-Confusion
Thirst
Lethargy
Seizures
Mr. Abdul, a 76-year-old male, has been admitted to the hospital with complaints of
having shortness of breath, headaches and blurred vision, fatigue, and increased
anxiety for the past week. He has begun experiencing tremors in his hand. The tremors
were so severe he was unable to fix his dinner or take his medication. He reports that
he has had increasing trouble keeping his balance when walking and had to borrow a
friend's cane for balance. He has a history of type I diabetes mellitus (DM), treated with
a daily dose of insulin with breakfast. He has smoked one pack of cigarettes per day for
56 years. He was diagnosed with chronic obstructive pulmonary disease (COPD) three
years ago. He has no known drug allergies (NKDA). - ANSWER-Temperature 36.5 °C
(97.7 °F)
Pulse 118 regular
Respirations 32 and labored
BP 160/100 mm Hg
Pulse oximetry 90% on room air
ABG on room air: pH 7.2, PaCO2 60 mm Hg, PaO2 73 mm Hg, HCO3− 25 mEq/L
Urine ketones: +2
Other assessment findings to note include:
Reflexes are +1 bilaterally.
Gait is slow and unsteady, frequently reaches out to wall or furniture to steady self.
Denies pain but is very restless.
Anxious demeanor. Slow to respond to questions. Unsure about answers to some
current events' questions.
Skin is warm, dry, and slightly pale.
Reported sleep quality is good and he says he sleeps about 10 hours at night and takes
two naps during the daytime.
Impaired Gas Exchange
Acute Confusion
,Self-Care Deficit
Question 1 of 12
A patient is admitted with an acid-base imbalance. The patient's current assessment
data includes hypotension and dysrhythmia. Which is the priority nursing diagnosis that
the nurse should include in the plan of care?
Decreased Cardiac Output
Acute Confusion
Impaired Gas Exchange
Fatigue - ANSWER-Decreased Cardiac Output
Acid-base imbalance, coupled with hypotension and dysrhythmia, indicates a priority
nursing diagnosis of Decreased Cardiac Output.
Question 1 of 4
Place the steps the nurse uses to analyze ABGs in the correct order.
1. Evaluate the PaO2 and O2 saturation level.
2. Evaluate the pH to determine if it is acidotic, alkalotic, or within normal range.
3. Evaluate the PaCO2 and HCO3- to determine if the imbalance is respiratory or
metabolic.
4. Evaluate whether or not compensation is occurring. - ANSWER-The steps the nurse
should take to analyze an ABG are to first evaluate the PaO2 and O2 saturation levels
to determine if hypoxemia is occurring. The next step is to evaluate the pH to determine
if it is acidotic, alkalotic, or within normal limits. The third step is to evaluate the PaCO2
and HCO3- to determine if the imbalance is respiratory or metabolic. The final step is to
determine if compensation is occurring.
Question 1 of 4
Which interventions should the nurse implement for a patient who is experiencing
respiratory acidosis?
Select all that apply.
Increase the rate of IV fluid administration
Encourage deep breathing exercises
Monitor breath sounds
Provide emotional support
Administer prescribed narcotic - ANSWER-Encourage deep breathing exercises
The nurse can independently encourage the patient to complete deep breathing
exercises.
Monitor breath sounds
The nurse should monitor the patient's breath sounds due to the current respiratory
status.
Provide emotional support
The nurse should provide emotional support for the patient who is experiencing an acid-
base imbalance.
Question 1 of 4
, Which NOC outcome is appropriate for Mr. Abdul's nursing diagnosis of Acute
Confusion?
Select all that apply.
Cognition
Distorted Thought Self-Control
Information Processing
Memory
Adherence Behavior - ANSWER-Cognition
Distorted Thought Self-Control
Information Processing
Memory
Question 1 of 4
Which questions should the nurse ask when conducting a health history assessment for
a patient who has a potassium imbalance?
Select all that apply.
"Do you have lactose intolerance?"
"Do you take a diuretic, such as furosemide (Lasix)?"
"Are you experiencing swelling in your feet?"
"Do you use a salt substitute on your food?"
"Do you eat canned meats or vegetables often?" - ANSWER-"Do you take a diuretic,
such as furosemide (Lasix)?"
Furosemide is a potassium-wasting diuretic, which can cause hypokalemia.
"Do you use a salt substitute on your food?"
Overuse of potassium-rich salt substitutes by people who have poor renal excretion
may cause hyperkalemia.
Question 1 of 8
A patient presents to the emergency department (ED) with a serum phosphate
concentration of 3.1 mEq/L. Which should the nurse assess this patient for based on
this laboratory value?
Select all that apply.
Tetany
Hyperreflexia
Decreased deep tendon reflexes
Muscle cramps
Shallow respirations - ANSWER-Tetany
A serum phosphate concentration greater than 2.6 mEq/L indicates
hyperphosphatemia. The nurse should assess for tetany, a clinical manifestation of
hypocalcemia caused by hyperphosphatemia.
Hyperreflexia
A serum phosphate concentration greater than 2.6 mEq/L indicates
hyperphosphatemia. The nurse should assess for hyperreflexia, a clinical manifestation
of hypocalcemia caused by hyperphosphatemia.
