Prepare: The Nursing Care of Altered Acid-Base Balance

Recognizing Cues: Altered Acid-Base Balance

• An arterial blood gas (ABG) test measures the acidity, levels of oxygen, bicarbonate and carbon dioxide in arterial blood.

Data Interpretation: Arterial Blood Gas Analysis

• Matt presents to the emergency department with severe vomiting for 72 hours, irritability, hand tremors and muscle cramps that began today. The health care provider prescribes several items, including an arterial blood gas (ABG). The nurse is using the Tic-Tac-Toe method to evaluate the results. Drag the elements used to evaluate acid-base balance to the correct locations for these results:

Prioritizing Cues: Worsening of Altered Acid-Base Balance

• While caring for Matt the nurse observes changes in the physical assessment. Which findings provide cues that Matt’s acidbase balance is getting worse? Select all that apply.

Self-Check: Recognizing Acid-Base Imbalance Cues

• Recognizing Acid-Base Imbalance Cues Based on the information provided for each person, indicate what type of acid-base balance they are experiencing by dragging their picture to the correct place in the table.

Self-Check: Nursing Action - ABG Results

The nurse is reviewing the arterial blood gas (ABG) results for Ms. Darling, admitted to the intensive care unit with pneumonia and 102.4° fever. The client is receiving oxygen at 4 L/min via nasal cannula.

• Based on the information in the medical record, what action will the nurse take?
• Select the choices to reflect Ms. Darling’s current acid-base status.

Self-Check: Nursing Action - Assessing Collateral Circulation to the Hand

• The nurse is preparing to complete an Allen’s test on a client admitted with salicylate overdose. Place the steps in order by arranging the images below from first to last of the actions present.

Self-Check: Prioritize Nursing Actions

• In which order will the nurse complete the prescribed actions, tests, and therapies? Place the items in order from the first action the nurse will take to the last.

Self-Check: Evaluation of Outcomes

• After Ms. Darling’s oxygen had been increased for 30 minutes the nurse returned to the room to take vital signs and assist with the repeat arterial blood gas (ABG) test. In Ms. Darling’s chart below, select which results demonstrate that her acid-base balance has improved. Be sure to review all tabs and select all proper answers.

Reflect: The Nursing Care of Altered Acid-Base Balance

Prioritizing Client Needs

• The nurse working in an urgent care center is reviewing the list of client’s to be assessed prior to being seen by the health care provider. Based on their reason for visit, place the client’s in the order in which the nurse should assess them, starting with the first on top

Cues to Altered Acid-Base Balance

• The nurse is concerned that which of these clients are at risk for acid-base imbalance? Select all that apply.

Delegating Client Care – Who Can Take Action

• The registered nurse (RN) is working with a licensed vocational nurse (LVN) and an unlicensed assistive personnel (UAP). Indicate which colleague can complete each action for each client by selecting the colleague role (RN, LVN, UAP) to the proper cell. Note: More than one colleague may be able to complete action.

Delegating Client Care: Who Should Take Action

• Now indicate which colleague should complete each action by dragging the registered nurse (RN), licensed vocational nurse (LVN), or unlicensed assistive personnel (UAP) to the proper cell. Note: Only one colleague should be assigned each action and all clients must have a caregiver assigned to all actions

Recognizing Cues in Verbal Report

• The licensed vocational nurse (LVN) calls the nurse out of Jason’s examination room and provides the following client report.

What is Wrong with Joshua?

• Based on data collected thus far, the nurse hypothesizes that Joshua Waymire is experiencing which acid-base imbalance?

Supporting Alterations in Acid-Base Balance

• After confirming the data provided by the licensed vocational nurse (LVN), the nurse anticipates that the healthcare provider will prescribe which actions to support and stabilize the client’s worsening acid-base status?

Arterial Blood Gas Sampling

• The nurse working in the emergency department is preparing to obtain arterial blood gas (ABG) specimens from several clients. For which clients should the nurse wait at least 15 minutes prior to collecting the sample? Select all that apply.

Respiratory Alkalosis

Prepare: Respiratory Alkalosis

Assessment Findings

David Jones is a 62-year-old widow who lives alone. He presents to the emergency department (ED) with shortness of breath and tingling in fingers. He denies having diabetes, respiratory illness, or significant cardiac history. Physical assessment reveals T 98.4, HR 108 reg, RR 32 and deep, BP 98/56. His speech is rapid, and he frequently changes his position in on the stretcher. Current medications include an antianxiety medication, and he says he has had anxiety attacks before.  Bedside testing results include blood glucose 98 and electrocardiogram (ECG) shows no changes.

• Based on the assessment data, the nurse hypothesizes Mr. Jones’s symptoms are being caused by what pathophysiologic process?
• The nurse just received the results of Mr. Jones’s arterial blood gas (ABG) test. What condition does the nurse report to the health care provider?

Recognizing Cues – Rapid Respiratory Rate

• Which conditions contribute to the development of respiratory alkalosis? Select all that apply.

Prioritizing Actions – Rapid Respiratory Rate

The healthcare provider has prescribed care for Mr. Jones. Indicate the actions the nurse will take by placing a check in the appropriate column for each.

Self-Check: Recognizing Cues - Jessa Smyth

• Select the assessment data that alerts the nurse that Ms. Smyth may be experiencing an acid-base imbalance.

Self-Check: Priority Actions - Ms. Smyth

• The nurse caring for Ms. Smyth plans to complete prescribed actions in priority order. For the actions listed below, drag into order from the first to be completed to the last.

Self-Check: Care Priorities - Ms. Smyth

• Based on the most recent data in Ms. Smyth's electronic health record (EHR) the nurse realizes that she is at risk for fat embolus as evidenced by x-ray results. To promote Ms. Smyth’s health, the emergency department nurse reinforces the need for immobilization of the left leg with the nurse receiving report when Ms. Smyth is admitted for surgery.

Self-Check: Change in Status - Ms. Smyth

• While reviewing the electronic health record (EHR) the nurse is called to Ms. Smyth’s room by the unlicensed assistive personnel (UAP). Upon entering the room the nurse sees Ms. Smyth telling the UAP to help her get up and dressed. The UAP provides this report.

Self-Check: Treating Anxiety - Ms. Smyth

• Ms. Smyth is restless and anxious as she awaits surgery to repair her leg. Based on these assessment findings, which medication does the nurse anticipate being prescribed?

Reflect: Respiratory Alkalosis

Who is at Risk – Respiratory Alkalosis

• Indicate which clients are at risk for respiratory alkalosis by selecting their picture. Select all that apply.

ABG Results: Respiratory Alkalosis

• Based on the listed arterial blood gas (ABG) results, indicate which acid-base disorder everyone is experiencing by dragging their name to the cell that corresponds to the cause (row) and condition (column) indicated by the results.

Priority Assessment – Liam

• Liam is a 19-year-old male preparing for a speech in his communications class. Liam appears sleepy and states he has a headache. His roommate has noticed increased anxiety over the last few days and encourages Liam to visit the student health clinic on campus. What priority assessment data does the nurse obtain first? Select all that apply.

Take Action – Liam

• Select each cell to indicate which health care provider prescriptions are indicated for Liam, non-essential for his care, or contraindicated based on his current condition.

Analyzing Data – Liam

• The nurse received the results of Liam’s arterial blood gas test. What condition does the nurse report to the health care provider?

Nursing Diagnosis – Liam

• Using a nursing diagnosis text, indicate which assessment findings are present in a client with anxiety, fear, and ineffective breathing patterns. Then indicate which are present in Liam’s assessment data (above).
• Based on the information provided, which nursing diagnosis should the nurse select for Liam?

Nursing Diagnosis – Liam

• Complete Liam’s nursing diagnosis statement by selecting the correct words/phrases from the drop-down menus within the sentence.

Discharge Teaching – Liam

• The nurse plans to include which items when providing discharge teaching to help Liam control his anxiety levels before they impact his health. Which items should the nurse included? Select all that apply.

Respiratory Acidosis

Prepare: Respiratory Acidosis

Recognizing Cues – Ineffective Gas Exchange

• Which conditions contribute to the development of respiratory acidosis? Select all that apply.

Cues and Hypotheses – Suspected Sedative Overdose

• Annie, an adult in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Her respiratory rate is 7 per minute and she is unresponsive to painful stimuli. An arterial blood gas shows pH 7.10, PaO2 78 mm Hg, PaCO2 70 mm Hg, and HCO3 24 mEq/L. The nurse understands Annie is experiencing which acid-base imbalance?

Prioritizing Actions – Correcting Respiratory Acidosis

• During a review of medications, the nurse identified that Annie received an opioid medication in error. The client's respirations are 10 per minute. Which interventions should the nurse anticipate being prescribed by the healthcare provider? Select all that apply.

Self-Check: Prioritizing Cues - Jessa Smyth

• Which two priority assessment findings that indicate Ms. Smyth is experiencing hypoxia require immediate follow up?

Self-Check: Priority Actions - Ms. Smyth

• The nurse caring for Ms. Smyth plans to complete prescribed actions in priority order. For the actions listed below, drag into order from the first to be completed to the last.

Self-Check: Care Priorities - Ms. Smyth

• Based on the most recent data in Ms. Smyths electronic health record (EHR), the nurse understands that she is at risk for hypoxia as evidenced by chest x-ray. To promote Ms. Smyth’s health, the nurse adds incentive spirometry to the nursing plan of care.

Self-Check: Change in Status - Ms. Smyth

• After reviewing the electronic health record (EHR) and contacting the primary care provider to recommend Ms. Smyth be prescribed incentive spirometry the nurse is called to Ms. Smyth’s room by the unlicensed assistive personnel (UAP). Upon entering, the nurse observes Ms. Smyth sitting in a chair, restless, without her oxygen in place. The UAP provides this report.

Which priority actions will the nurse perform to gather cues related to the change in Ms. Smyth’s behavior and respiratory status? Click on the three actions the nurse will complete first.

Self-Check: Evaluation of Outcomes - Ms. Smyth

• Select the cues from the documentation that indicate to the nurse that Ms. Smyth’s condition is improving after actions taken by the nurse.

Reflect: Respiratory Acidosis

Assessment – Damien

• Which three assessment findings alert the nurse to a potential alternation in acid-base balance? Select the cues by clicking on them.

Analyzing Data – Damien

• The nurse received the results of Damien’s arterial blood gas test. What condition does the nurse report to the health care provider?

Promoting Lung Health – Damien

• The nurse determines that Damien is at risk for ineffective respiratory function due to his chronic obstructive pulmonary disease (COPD) and pneumonia. Which actions does the nurse plan to promote carbon dioxide excretion and stable acidbase balance? Select all that apply.

Take Action – Damien

• The chest x-ray shows patchy alveolar opacification in the right upper and left lower lobes. Select each cell to indicate which healthcare provider prescriptions are indicated for Damien, non-essential for his care, or contraindicated based on his current condition.

Expected Outcomes – Damien

• The nurse and Damien discuss goals for his care and expected health outcomes. Which expected outcomes should the nurse include in the plan of care? Select all that apply.

Cues to Altered Acid-Base Balance

• George Kent is a 54-year-old widower with a history of chronic obstructive pulmonary disease. He was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. The nurse anticipates which acid-base imbalance?

Client Education – Respiratory Acidosis

• The nurse is providing discharge teaching to the client with the narcotic overdose and treated for respiratory acidosis. Which recommendations should the nurse provide ? Select all that apply.

Acid-Base Disorder

• Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. The parent reports seeing slight tremors and behavioral changes in the child over the past four days. The healthcare provider orders routine arterial blood gas (ABG) testing. The ABG results are pH 7.35, PaCO2 72 mmHg, and HCO3 38 mEq/L. What acidbase disorder is shown?

Metabolic Alkalosis

Prepare: Metabolic Alkalosis

Assessment Findings

Carole Jeanne presents to the emergency department with a recent onset of weakness, fatigue, palpitations, and muscle cramping. She denies having diabetes, respiratory illness, or significant cardiac history other than hypertension that is controlled with a prescribed antihypertensive and diuretic. Physical assessment reveals T 98.4, HR 108 irregularly irregular, RR 14, and BP 110/66. During the assessment Carole Jeanne tells the nurse that she has been taking twice the prescribed diuretic for the last two weeks to “get some weight off before my daughter’s wedding.”

• Based on the assessment data, the nurse hypothesizes Mr. Jones’s symptoms are being caused by what pathophysiologic process?
• The nurse just receives the results of Carole Jeanne’s arterial blood gas test. What condition should the nurse report to the health care provider?

Data Interpretation – Metabolic Alkalosis

• When reviewing a client’s medical record the nurse is aware that which conditions contribute to the development of metabolic alkalosis? Select all that apply.

Prioritizing Actions

• Based on the Carole Jeanne’s condition, the health care provider writes these orders. The nurse plans to act on which priority items first? Select two items by clicking on them.

Self-Check: Identifying Clients at Risk for Metabolic Alkalosis

• While receiving report at the start of a shift, the charge nurse identifies which clients are at highest risk for metabolic alkalosis? Select all that apply.

Self-Check: Ongoing Assessment - Metabolic Alkalosis

• Based on Carole Jeanne’s symptoms of weakness, fatigue, palpitations and muscle cramping and observed signs of slow respirations, irregular heart rate, and reported overuse of diuretics, the nurse should complete a focused assessment on which systems? Use the drop-down menus to indicate if the nurse should or should not complete a focused assessment.

Self-Check: Nursing Diagnoses - Metabolic Alkalosis

• Based on Diana's assessment data, the nurse selects which two priority nursing diagnoses? Select all that apply.

Self-Check: Modified Allen Test

• The health care provider has ordered a repeat arterial blood gas with potassium for Diana. Prior to obtaining blood from the radial artery the nurse assesses collateral circulation from the ulnar artery by occluding both arteries of one hand while the person makes a fist several times. After the skin blanches the nurse asks the person to open the hand without hyperextending it before releasing pressure on the ulnar artery while maintaining pressure on the radial artery. Adequate circulation is suggested by a return to the normal color of the hand in less than 7 seconds

Self-Check: Evaluation - Metabolic Alkalosis

Evaluation – Metabolic Alkalosis

• The nurse reviewing the repeated laboratory results determines that Diana's acid-base imbalance has improved based on which values? Select all that apply.

Reflect: Metabolic Alkalosis

Prioritizing Cues – Metabolic Alkalosis

• The emergency department nurse is assessing Harold, an adult client. Which information shared during the health history alerts the nurse to follow-up immediately? Select all that apply.

Nursing Diagnosis – Metabolic Alkalosis

• Based on the information provided, the nurse recognizes that Harold is at high risk for seizures and dysrhythmias related to altered serum electrolytes brought on by overuse of antacids.

Assessment Findings

During emergency surgery to remove a ruptured appendix, the contents of the client's upper gastrointestinal tract were evacuated to prevent aspiration. Arterial blood gas values after.

• The nurse correctly links the arterial blood gas results to which actions taken during the surgical procedure?
• The nurse correctly identifies that the client is experiencing which acid-base imbalance?
• The nurse caring for the client post-operatively should prioritize assessment of which systems based on the current acid-base balance? Select all that apply.

Colleague Education – Metabolic Alkalosis

• The nurse assess that a new colleague understands the basics of acid-base balance by asking them to match the changes in carbon dioxide (PaCO2) and bicarbonate (HCO3‾) to the condition caused by the changes. How should the new colleague complete the activity? Match the laboratory values and acid-base imbalances into the correct pairs.

Taking Action – Acid-Base Imbalance

• A 26-year-old was taken to the hospital by friends due to nausea, vomiting, and overall weakness. After a series of tests, the nurse notes the potassium is 2.9 mEq/L. Which action should the nurse take first?

Interpreting Data

• A client who is one day post-abdominal surgery, has a nasogastric tube (NGT) . The nurse notes that the NGT is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the health care provider, and a STAT arterial blood gas test is ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3‾ 30 mEq/L. Which alteration in acid-base balance should the nurse report to the health care provider?

Metabolic Acidosis

Prepare: Metabolic Acidosis

Recognizing Cues – Altered Metabolic Processes

• Which conditions contribute to the development of metabolic acidosis? Select all that apply.

Cues and Hypotheses – Acid-Base Imbalance

• A young adult was transported to the emergency department by friends who suspect they ingested ethylene glycol and a large amount of acetylsalicylic acid. The nurse plans to assess the client for which acid base imbalance?

Nursing Diagnoses – Metabolic Acidosis

• The nurse is caring for a client who has been admitted with persistent diarrhea lasting 3 days. Which are appropriate nursing diagnoses for this client during the acute phase of the illness? Select all that apply.

Self-Check: Clustering Cues – Carl

• Based on the presenting history, the nurse concludes this client is experiencing complications of which disease?

Self-Check: Priority Actions – Carl

• The nurse is reviewing Carl’s lab results and the health care provider’s orders. Which actions should the nurse complete first? Select the top three actions the nurse should take.

Self-Check: Arterial Blood Gas Interpretation – Carl

• Based on the laboratory results, the nurse should inform the primary care provider that Carl is experiencing which acid-base imbalance?

Self-Check: Planning Nursing Care – Carl

• The nurse is reviewing Carl’s most recent assessment data to update the plan of care. In the table below, select the potential complication that Carl is most likely to experience, actions the nurse should take to address that complication, and the parameters the nurse should monitor to assess for that complication.

Self-Check: Evaluation – Carl

• Based on the most recent arterial blood gas results and nurse’s note, the nurse informs Carl and his parents that he is now experiencing uncompensated metabolic acidosis and his condition is improving. The nurse adds that his condition is serious and will remain that way until his serum pH and glucose return to normal levels.

Reflect: Metabolic Acidosis

Assessment – James

• Which assessment findings alert the nurse to a potential alternation in acid-base balance? Drag the three (3) highest priority cues that provide evidence of an acid-base imbalance to the drop zone.

Analyzing Data – James

• The nurse is reviewing James’s laboratory results and correctly interprets that his acid- base balance was normal at 13:00 yesterday and now show he is experiencing combined respiratory and metabolic acidosis.

Taking Action – James

• When acting on the most recent health care provider orders for James the nurse should complete them in what order? Place the actions in priority order, starting with the highest priority action first.

Delegating Actions – James

• The nurse can safely delegate which actions to an unlicensed assistive personnel (UAP)?

Expected Outcomes – James

• The nurse is discussing with the unlicensed assistive personnel (UAP) the three expected outcomes for James between now and when he is transferred to the intensive care unit (ICU). Which priority outcomes should the nurse include? Select on all that apply.

Underlying Conditions – Acid-Base Imbalance

• The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder?

Interpreting Cues

• An unresponsive client is brought to the emergency department by paramedics after overdosing on an unknown quantity of aspirin. The client’s respirations are rapid and deep. The client’s partner reports the bottle of aspirin (325 mg per pill) was new and contained 240 tablets and the bottle was empty when the client was found. Based on this information, which acid-base imbalance does the nurse anticipate?

Initial Assessment – Metabolic Acidosis

• A client with renal failure who missed two dialysis sessions calls the nurse healthline because she is feeling sick. Based on this brief history, the nurse should assess for which symptoms?