Author Question: A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood ... (Read 33 times)

Shelles · **on:** Jun 25, 2018

A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3- 16 mEq/L. What action should the nurse take next?

a. Assess client's rate, rhythm, and depth of respiration.
b. Measure the client's pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the physician as soon as possible.

Question 2

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19 mEq/L. Which assessment should the nurse perform first?

a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation

jamesnevil303 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

Answer to Question 2

ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographi c changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.