Electrolytes Question #64

Question

The nurse is caring for a client with diabetes who has nausea, severe abdominal pain, weakness, and bradycardia. Arterial blood gas (ABG) are a pH of 7.1 and a bicarbonate level of 18 mEq/L. Which assessment findings will the nurse anticipate? Select all that apply.

Answers

  1. Cold, clammy diaphoretic skin
    • Rationale:
  2. Tachycardia
    • Rationale:
  3. Warm flushed skin
    • Rationale:
  4. Kussmaul’s respirations
    • Rationale:

Overview

Explanation

The correct answer is C & D. Metabolic acidosis occurs when the body produces too much acid. The skin will be warm with this condition. Kussmaul respirations, or deep labored breathing, is often associated with metabolic acidosis. Cold, clammy diaphoretic skin and tachycardia are not associated with metabolic acidosis. .

NCLEX TIP: When answering select all that apply (SATA) questions, look at each answer option and ask yourself if the response is true or false. When looking at the questions, watch for any negative NCLEX words, which will lead the nurse to do the “wrong” tasks. These words may include always, never, ever, no, don’t, do not, etc. Always remember the ABC’s and Maslow’s hierarchy. Common words and phrases in the question should always be noted, and note when to delegate and not to delegate care. Never delegate a nursing task that requires an order, requires a higher intervention, or is being provided to an unstable client. And always remember an unstable client before a stable client.

Learning Outcomes

Test Taking Tip

Video Rationale