Chapter 14

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking
for Collaborative Care, 6th Edition

Test Bank
Chapter 14: Assessment and Care of Patients with Acid-Base Imbalances
MULTIPLE CHOICE
1.
A.
B.
C.
D.
Which client is at greatest risk for acidosis?

The 78-year-old client on diuretic therapy with furosemide (Lasix, Furoside)
The 62-year-old client with moderate hypertension
The 75-year-old client with peptic ulcer disease
The 45-year-old client with pneumonia
ANS: D
Any respiratory problem can lead to oxygen insufficiency and carbon dioxide retention.
The lack of oxygen also increases carbon dioxide production. The excessive levels of
carbon dioxide result in greatly increased hydrogen ion production and acidosis through
the carbonic acid pathway.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and
Maintenance;
2. Which acid-base imbalance should the nurse be prepared for in a client who has acute
pancreatitis?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
ANS: A
The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative
metabolic acidosis through the underproduction of bicarbonate ions.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;
3. Which laboratory data and clinical manifestations should cause the nurse to suspect a
client may be experiencing acidosis?
A. A serum sodium level of 130 mEq/L and peripheral edema
B. A serum sodium level of 144 mEq/L and tachycardia
C. A serum potassium level of 6.5 mEq/L and flaccid paralysis
D. A serum potassium level of 4.5 mEq/L and hyperactive deep tendon reflexes.
ANS: C
When acidosis is present, the hydrogen ion concentration of the extracellular fluid (ECF)
is increased above normal. Physiologic action to reduce the ECF hydrogen ion
concentration is to move the hydrogen ions into the cells in exchange for potassium ions
to maintain electroneutrality of the intracellular fluid. As a result, acidosis is
accompanied by hyperkalemia, which diminishes nerve and skeletal muscle excitability,
causing flaccid paralysis.
TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;
4. The handgrasps of the client with acidosis have diminished since the previous
assessment 1 hour ago. What is the nurses best first action?
A. Assess the client's rate, rhythm, and depth of respiration.
B. Measure the client's pulse and blood pressure.
C. Document the findings as the only action.
D. Notify the physician.
ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of the
acidosis. Muscle weakness can lead to severe respiratory insufficiency.
TOP: Nursing Process Step: Implementation/Intervention
5. Which ECG change from baseline indicates that the therapy for the client's acidosis is
effective?
A. Small U wave
B. Heart rate decrease to 62 bpm
C. T waves present and 2 mm high
D. P wave precedes the QRS complex
ANS: C
Acidosis and the accompanying hyperkalemia affect cardiac conduction, inducing tall T
waves, widened QRS complexes, and prolonged PR intervals. When T waves return to a
height of less than 3 mm, acidosis and hyperkalemia are resolving.
TOP: Nursing Process Step: Evaluation
6. Which process or condition is likely to have resulted in the arterial blood gas values
listed below?
pH 7.12, HCO3 22 mEq/L, PCO2 65 mm Hg, PO2 56 mm Hg
A. Diabetic ketoacidosis as a result of a urinary tract infection in a person with
emphysema
B. Complete tracheal obstruction suffered as a result of aspirating a hot dog
C. Anxiety-induced hyperventilation
D. Diarrhea for 36 hours
ANS: B
The arterial blood gas values indicate that the client is in acidosis and has normal levels
of bicarbonate, indicating that the problem is not metabolic. The arterial concentrations of
oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide
levels; thus, this client has respiratory acidosis from inadequate gas exchange. The fact
that the bicarbonate level is normal indicates that this is an acute respiratory problem
rather than a chronic problem, because there has been no renal compensation.
MSC: Client Needs Category: Physiological Integrity
7.
A.
B.
C.
D.
Which client is at greatest risk for the development of metabolic acidosis?

56-year-old man with chronic asthma
36-year-old man hiking in the Canadian Rockies
36-year-old woman on a carbohydrate-free diet
56-year-old woman self-medicating with sodium bicarbonate for gastroesophageal
reflux
ANS: C
One cause of acidosis is a strict, low-calorie diet or one that is low in carbohydrate
content. Such a diet increases the rate of fat catabolism and results in the formation of
excessive ketoacids.
MSC: Client Needs Category: Health Promotion and Maintenance/Physiological
Integrity;
8. Which set of arterial blood gas values represents partially compensated metabolic
acidosis?
A. pH 7.28, HCO3 19 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg
B. pH 7.45, HCO322 mEq/L, PCO2 40 mm Hg, PO2 98 mm Hg
C. pH 7.32, HCO 17 mEq/L, PCO 25 mm Hg, PO 98 mm Hg
3
2
2
D. pH 7.48, HCO3 28 mEq/L, PCO2 45 mm Hg, PO2 92 mm Hg
ANS: C
The pH is lower than normal, indicating mild acidosis. The acidosis is metabolic in
origin, as indicated by the normal arterial oxygen partial pressure and the low bicarbonate
level. The decreased carbon dioxide level indicates an increased respiratory rate, causing
the carbon dioxide to be blown off, bringing the pH closer to normal (but not
completely normal). Thus, the metabolic acidosis is only partially compensated by the
respiratory effort.
9. The client has just experienced a 90-second grand mal seizure and has the arterial
blood gas values shown below. How should the nurse be prepared to intervene?
A. Applying oxygen by mask or nasal cannula
B. Applying a paper bag over the client's nose and mouth
C. Administering 50 mL of sodium bicarbonate intravenously
D. Administering 50 mL of 20% glucose and 20 units of regular insulin
ANS: A
The client has experienced a combination of metabolic and acute respiratory acidosis
through heavy skeletal muscle contractions and no gas exchange. When the seizures have
stopped and the client can breathe again, the fastest way to return to acid-base balance is
to administer oxygen. Sodium bicarbonate should not be administered because the client's
arterial bicarbonate level is normal. Applying a paper bag over the client's nose and
mouth would worsen the acidosis.
10. Which is the most important intervention for the nurse to teach the client who is
going home and continues to be at risk for the development of metabolic acidosis?
A. Increase your intake of milk to at least three glasses daily.
B. Be sure to eat three well-balanced meals and a snack daily.
C. Avoid taking pain medication and an antihistamine at the same time.
D. Restrict your use of sodium by not adding salt to your food during meals.
ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing
cells to switch to using fats for fuel and by creating ketoacids as a by-product of
excessive fat metabolism. Eating sufficient calories from all food groups helps reduce
this risk.
MSC: Client Needs Category: Health Promotion and Maintenance
11.
A.
B.
C.
Which client is most at risk for the development of acute respiratory acidosis?
58-year-old man with allergic rhinitis and sinusitis
28-year old woman with type 1 diabetes who has a urinary tract infection
68-year-old woman who has long-standing emphysema and is now undergoing
continuous nasogastric suctioning
D. 38-year-old, 6' 7" man being mechanically ventilated with a tidal volume of 500 mL
at 15 breaths/minute
ANS: D
The ventilator settings for the man undergoing mechanical ventilation are based on the
tidal volume and ventilation needs of an "average"-sized person. This man would have a
tidal volume between 800 and 900 mL and is being seriously underventilated at the given
settings.
TOP: Nursing Process Step: Assessment/Evaluation
Maintenance;
12. Which process or condition is likely to have resulted in the arterial blood gas values
listed below?
A. Diarrhea for 36 hours
B. Anxiety-induced hyperventilation
C. Complete tracheal obstruction suffered as a result of aspirating a hot dog
D. Diabetic ketoacidosis as a result of a urinary tract infection in a person with
long-standing emphysema
ANS: B
The elevated pH indicates alkalosis. The bicarbonate level is normal and so is the oxygen
partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur
in response to hyperventilation.
13. The client has sustained multiple injuries and hemorrhage from a motor vehicle crash
and has received six units of packed red blood cells in the past 6 hours. To what
acid-base imbalance should the nurse be alert for as a possible complication of this
therapy?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
ANS: A
Citrate is a substance used as a preservative in blood products. It is not only a base, but
also a precursor for bicarbonate (bicarbonate can be formed from citrate). Rapid
administration of blood products can cause metabolic alkalosis by infusing large amounts
of citrate intravenously. Although this problem is more likely to occur with the
administration of whole blood or blood plasma, multiple transfusions with packed red
cells can also result in excessive amounts of citrate being received by the client.
14. What is the priority nursing diagnosis or collaborative problem for a client with
severe metabolic alkalosis?
A. Excess Fluid Volume related to reduced kidney function
B. Potential for Oversedation related to inadequate cerebral oxygenation
C. Risk for Impaired Skin Integrity related to accompanying peripheral edema
D. Risk for Injury related to increased neuronal sensitivity from accompanying
hypocalcemia
ANS: D
Metabolic alkalosis is manifested by a high pH, which causes serum calcium to bind and
reduces the concentration of free calcium. This relative hypocalcemia increases the risk
for increased neuromuscular activity, including tetany and seizures.
15. Which set of arterial blood gas values represents fully compensated respiratory
acidosis?
A. pH 7.28, HCO3 12 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg
B. pH 7.32, HCO3 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg
C. pH 7.35, HCO3 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg
D. pH 7.48, HCO3 12 mEq/L, PCO2 35 mm Hg, PO2 85 mm Hg
ANS: C
The pH is normal, indicating acid-base balance (fully compensated). A respiratory
problem with carbon dioxide retention and inadequate gas exchange is apparent from the
high PCO2 and the low PO2. The bicarbonate level is greatly elevated, indicating renal
synthesis and reabsorption of HCO3, a powerful acid-base compensatory mechanism.
Thus, the amount of bicarbonate (base) in the blood adequately compensates for the
increased carbon dioxide level, so that the pH is normal (although no other arterial blood
gas value is normal).
TOP: Nursing Process Step: Evaluation
16.
A.
B.
C.
D.
Which client is at continuing risk for alkalosis?

35-year-old critically ill client receiving total parenteral nutrition
45-year-old client with type 1 diabetes, once-daily insulin therapy
55-year-old client with metastatic breast cancer on continuous IV morphine
65-year-old client with occupation-induced asthma using an adrenergic agonist
inhaler
ANS: A
The intravenous fluid mixture for total parenteral nutrition (TPN) has an overall basic pH.
One common substance in TPN is lactate, which is rapidly converted in the body to
bicarbonate. In addition, the TPN mixture is often administered as a continuous slow
infusion. The age of the client is not significant in this question.
Maintenance;
17. The client has salicylate poisoning. Which assessment findings should the nurse
expect to be associated with this problem?
A. Increased deep tendon reflexes
B. Increased rate and depth of respiration
C. Circumoral cyanosis and slow capillary refill
D. Decreased intestinal motility and paralytic ileus
ANS: B
Salicylates are acidic and salicylate poisoning increases the rate and depth of ventilation
in two ways. First, salicylates directly stimulate the respiratory centers. Secondly, by
causing a metabolic acidosis, and reducing the pH of the blood, the respiratory centers are
stimulated to compensate.
18. How does prolonged fever contribute to acid-base imbalances?
A. Fever alone does not cause acid-base imbalances; rather, the conditions causing the
fever are responsible for various types of imbalances.
B. Prolonged fever induces dehydration and hyperkalemia, resulting in a compensatory
movement of hydrogen ions and metabolic alkalosis.
C. Fever increases the rate of metabolism, causing a metabolic acidosis by increasing
the rate of carbon dioxide production.
D. Fever dries the pulmonary mucous membranes, impairing gas exchange and causing
a respiratory alkalosis.
ANS: C
Increased body temperature is associated with hypermetabolism and increases the rate at
which carbon dioxide is produced.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
19. Which statement by the client should alert the nurse to a need for further instruction
regarding an increased risk for metabolic alkalosis?
A. I don't drink milk because it gives me gas and diarrhea.
B. I have been taking digoxin every day for the last 15 years.
C. I take sodium bicarbonate after every meal to prevent heartburn.
D. In hot weather, I sweat so much that I have to drink at least six glasses of water
each day.
ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can
cause a metabolic alkalosis.
20. The client with chronic respiratory acidosis who is receiving oxygen by nasal cannula
at 10 L/min now has a respiratory rate of 8. What is the nurses best action?
A. Document the observation as the only action.
B. Change the nasal cannula to an oxygen mask.
C. Place the client in a high-Fowler's position.
D. Decrease the oxygen flow rate.
ANS: D
The primary trigger for respiration in a client with chronic respiratory acidosis is a
decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory
effort in this case, eventually causing death.
21. How does a relative alkalosis differ from an actual alkalosis?

A. In an actual alkalosis, the amount of base components is increased and, in a relative
alkalosis, the amount of acid components is decreased.
B. A relative alkalosis results from underelimination of base components and an actual
alkalosis results from an overproduction of base components.
C. Relative alkalosis occurs with dehydration in which there is no real change in the
amount or strength of base components.
D. There is no difference between an actual and a relative alkalosis.
ANS: A
An actual alkalosis occurs with an actual increase in the amount and/or strength of base
components (a base excess alkalosis). A relative alkalosis occurs when there has been no
change in the amount and/or strength of base components but there has been a loss of
acid components (an acid-deficit alkalosis).
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A
22. Which acid-base imbalance should the nurse be most alert for when providing care to
a client who has several broken ribs?
A. Respiratory alkalosis from anxiety
B. Respiratory acidosis from inadequate ventilation
C. Metabolic acidosis as a result of calcium loss from broken bones
D. Metabolic alkalosis as a result of ingesting base-containing analgesics
ANS: B
Pain from broken ribs often causes the client to breathe more shallow to avoid moving
the ribs and increasing pain. If respiration is shallow enough, ventilation is inadequate,
leading to poor gas exchange and respiratory acidosis.
23. With which of the following clients should the nurse be prepared to administer
bicarbonate intravenously?
A. 25-year-old client with an acute asthma attack who has the following arterial blood
gases: pH 7.28, HCO3 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg
B. 25-year-old client with excessive diarrhea who has the following arterial blood
gases: pH 7.28, HCO3 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg
C. 65-year-old client with chronic emphysema and bronchitis who has the following
arterial blood gases: pH 7.30, HCO3 30 mEq/L, PCO2 60 mm Hg, PO2 72 mm Hg
D. 65-year-old client with a urinary tract infection and type 2 diabetes who has the
following arterial blood gases: pH 7.31, HCO3 20 mEq/L, PCO2 34 mm Hg, PO2
96 mm Hg
ANS: B
The only client who has lower than normal bicarbonate levels is the client with diarrhea.
This deficit is most likely an actual bicarbonate loss and should be replaced to help return
this clients acid-base balance back to normal. Giving bicarbonate to any of the other
clients listed would be adding too much base and would risk pushing them into alkalosis.
24. The client has metabolic alkalosis as a result of excessive ingestion of a
base-containing antacid and drinking more than 2 L of milk daily as a home remedy
for heartburn. Which electrolyte imbalance should the nurse expect to accompany
this condition?
A. Hyponatremia
B. Hypernatremia
C. Hypokalemia
D. Hyperkalemia
ANS: C
Both potassium and hydrogen ions carry or express an overall positive charge (are
cations). Body fluids maintain electroneutrality by keeping the number of positive ions
matched with an equal number of negative ions (anions). A compensation of alkalosis is
the movement of hydrogen ions inside cells into the blood and other extracellular fluids.
To prevent the blood from expressing too many positive charges, another positive ion
must leave the blood and enter the cells. Potassium is the positive ion that is usually
exchanged for a hydrogen ion. Thus, a relative hypokalemia usually accompanies
alkalosis as extracellular potassium ions move into cells in exchange for intracellular
hydrogen ions entering the extracellular fluid.
25. The family of a client who has a combined respiratory and metabolic acidosis as a
result of bronchitis and diabetic ketoacidosis asks the nurse whether the clients
confusion is likely to be permanent. What is the nurses best response?
A. It is too early to tell if the ketoacids will be permanently retained.
B. Yes, although her memory will improve with time, some brain cell loss has
occurred.
C. Probably not. The confusion should clear as soon as her oxygen and electrolyte
levels are normal.
D. Probably not. The confusion should clear as soon as her pH and blood glucose
levels are normal.
ANS: C
The pH abnormality alone is not responsible for the confusion. Most of the confusion is
caused by the hypoxia in combination with the electrolyte imbalances that accompany
severe, combined acidosis.
MSC: Client Needs Category: Psychosocial Integrity
26. Which is the best intervention for the nurse to teach the client who is going home and
continues to be at risk for the development of metabolic alkalosis?
A. Avoid excess use of antacids.
B. Increase your intake of milk to at least three glasses daily.
C. Avoid aspirin and aspirin-containing over-the-counter medications.
D. Restrict your use of sodium by not adding salt to your food during meals.
ANS: A
Many antacids contain either bicarbonate or calcium carbonate, both of which (when
taken in excess) can increase the bicarbonate content of the blood and other extracellular
fluids, increasing the risk for alkalosis even more.
27. Which specific electrolyte level is most important for the nurse to monitor in a client
who has any type of acid-base imbalance?
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
ANS: C
Any type of acid-base imbalance usually alters the blood potassium level. Both potassium
and hydrogen ions carry or express an overall positive charge (are cations). Body fluids
maintain electroneutrality by keeping the number of positive ions matched with an equal
number of negative ions (anions). In acidosis, hydrogen ions enter cells in exchange for
potassium ions. Thus, a relative hyperkalemia accompanies acidosis. In alkalosis,
hydrogen ions leave the cells and enter the blood in exchange for potassium ions. Thus, a
relative hypokalemia usually accompanies alkalosis as extracellular potassium ions move
into cells in exchange for intracellular hydrogen ions entering the extracellular fluid.
Normal potassium level of the blood has a narrow range (3.5 to 5.0 mEq\L). When blood
potassium levels are too high, lethal cardiac dysrhythmias may occur. When blood
potassium levels are too low, skeletal muscle weakness and respiratory failure may occur.
DIF: Cognitive Level: Comprehension
OTHER
1. Indicate whether the following factors/conditions/pathologies are most commonly
associated with
A. Respiratory acidosis
B.
Metabolic acidosis
C.
Common to both respiratory and metabolic acidosis
D.
Common to neither respiratory nor metabolic acidosis
_____ hyperkalemia
_____ decreased bicarbonate
_____ elevated PaO2
_____ elevated PaCO2
_____ increased concentration of hydrogen ions
_____ increased binding of drugs to plasma proteins
ANS:
__C__ hyperkalemia
__B__
decreased bicarbonate
__D__
elevated PaO2
__A__
elevated PaCO2
__C__
increased concentration of hydrogen ions
__D__
increased binding of drugs to plasma proteins
Rationale: Acidosis of either origin is reflected by a relative or an actual increase in
hydrogen ions that express an overall positive charge. To try and maintain
electroneutrality as well as acid-base balance, these extra hydrogen ions are moved into
cells in exchange for potassium ions. Thus, any type of acidosis is accompanied by
hyperkalemia. The only underlying pathology for respiratory acidosis is poor gas
exchange with retention of carbon dioxide, leading to increased production of hydrogen
ions. Bicarbonate loss does not contribute to a pure respiratory acidosis but may be the
cause of a metabolic relative acidosis (base deficit acidosis). Neither respiratory nor
metabolic processes leading to acidosis increase the oxygen concentration. In respiratory
acidosis, the problem of poor gas exchange can reduce the oxygen concentration but
cannot increase it. High concentrations of hydrogen ions, with a low pH, change the
shape of plasma proteins and other proteins, reducing the fit of drugs with their protein
receptors and thus reducing the binding of drugs to plasma proteins.

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Chapter 14

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Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking

for Collaborative Care, 6th Edition

Which client is at greatest risk for acidosis?

Which client is at greatest risk for the development of metabolic acidosis?

Which client is at continuing risk for alkalosis?

21. How does a relative alkalosis differ from an actual alkalosis?

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