MODULE 1: THE CONCEPT OF ACID–BASE BALANCE
Clinical Examples A–C
Clinical Example A (p. 7)
Jay James is a 24-year-old man who was rock climbing with his friends at a national park
25 miles from the nearest hospital when he suddenly lost his footing and slid 20 feet to the
ground. Mr. James was alert and oriented when his friends reached him, and he could move
all extremities quite easily. He had multiple scrapes over his anterior chest and a large gash
over his left thigh (near the groin), which was bleeding profusely. His friends made a
makeshift tourniquet, which slowed the bleeding. They immediately contacted the park
ranger, who secured a helicopter to evacuate Mr. James to the nearest hospital.
Two large-bore IVs were placed in each arm in-flight, and normal saline was administered.
The flight medic placed a 100% nonrebreathing mask on Mr. James. Mr. James became
disoriented and confused during the flight. Mr. James arrived in the emergency department
(ED) 45 minutes after the fall.
On arrival in the ED, Mr. James is lethargic but responsive to painful stimuli. He has
multiple abrasions over his chin and neck. His pulse oximetry is 99% on the nonrebreather
mask, so the ED team replaces the mask with a nasal cannula at 4 L/m. A repeat pulse
oximeter reads 95% saturation.
Vital signs are as follows: TO 37.3°C (99.1°F): HR 130 bpm; R 30/min; and BP 100/60
mmHg. Skin is cool and clammy, nail beds are pale, and mucous membranes are dry. All
pulses are palpable but weak and thready. Lungs are clear, heart sounds regular. Output via
urinary catheter for the past hour is 20 mL.
Clinical Reasoning Questions Level I
Question 1
What is the most likely cause of Mr. James’s high heart rate and low blood pressure?
Answer 1
The most likely cause of the high heart rate and low blood pressure is shock related to loss
of blood, which causes compensatory high heart rate and low blood pressure related to
volume loss.
Question 2
If you were the nurse assigned to Mr. James, what would be your primary concerns at this
time?
Answer 2
The primary concerns would be loss of blood and unstable vital signs.

Clinical Reasoning Questions Level II
Question 3
What is the priority nursing diagnosis for Mr. James at this time?
Answer 3
The priority nursing diagnosis is fluid volume deficit related to hypovolemia, and confusion
related to decreased blood flow to the brain.
Question 4
Why is Mr. James exhibiting confusion and disorientation?
Answer 4
With blood loss there is decreased blood/fluid volume and decreased circulation of
oxygenation to the brain, which leads to confusion and disorientation.
Question 5
What diagnostic tests would you expect to be ordered for Mr. James?
Answer 5
The expected diagnosis tests would be chest x-ray, CT scan, arterial blood gases, and serum
labs that include chemistry, blood count, and coagulation.
Clinical Example B (p. 11)
Anna Zemakis is a 49-year-old woman admitted to the hospital with severe vomiting and
muscle weakness. She fell 2 weeks ago and reports not feeling well since. Four days ago,
she developed abdominal discomfort with vomiting. The vomiting has been severe, and she
has not been able to eat or drink very much. She says she has lost a significant amount of
weight. She has felt very weak, anorexic, and lethargic. She has not had diarrhea or urinary
symptoms. There is no significant past medical history, and she reports she is not on any
prescribed medications or taking anything over-the-counter. Ms. Zemakis’s vital signs are
as follows: TO 37.7°C (98.9°F): HR 84 bpm; R 18/min; BP 90/58 mmHg (sitting), BP
110/60 mmHg (lying); pulse oximetry 98% on room air. Her lungs are clear, and her heart
sounds normal. You observe she has dry mucous membranes. Initial examination reveals
slight abdominal tenderness.
Clinical Reasoning Questions Level I
Question 1
What is Ms. Zemakis’s primary health problem?
Answer 1
The primary health problem is dehydration.
Question 2
As the nurse assigned to Ms. Zemakis, what are your concerns at this time?

Answer 2
Hypotension, dehydration, and lethargy are the main concerns.
Clinical Reasoning Questions Level II
Question 3
What nursing diagnoses are appropriate for Ms. Zemakis at this time? Which takes priority?
Answer 3
The nursing diagnosis is Fluid Volume: Deficient related to hypovolemia. Volume
replacement (IV hydration) is the priority.
Question 4
What therapies would assist Ms. Zemakis in returning to homeostasis?
Answer 4
Fluid replacement with normal saline 0.9% by IV infusion would return the patient to
homeostasis.
Question 5
Referring to the module on Perfusion: What is the significance of the different blood
pressure readings in different positions?
Answer 5
Postural (orthostatic) hypotension is a significant decrease in BP with a change in body
position from supine to sitting/standing or from standing/sitting.
Clinical Example C (p. 12)
John Quinland is a 60-year-old man with a 45-year history of smoking two packs of
cigarettes a day. Over the past year, he has become increasingly short of breath. At first, he
noticed this only when exercising, but now he is short of breath even at rest. Over the past
year, he has had several infections of the lower respiratory tract that were treated
successfully with antibiotics at the local ED. His shortness of breath has not subsided, and
he uses his accessory muscles of respiration to assist him in breathing. Mr. Quinland does
not have a primary care provider and does not get physical examinations. He had his last
physical over 20 years ago to meet a work requirement. Mr. Quinland goes to the nearest
hospital when he has a respiratory infection. The ED physician advises Mr. Quinland to find
a healthcare provider because he needs routine checkups, but Mr. Quinland does not take
the advice.
Clinical Reasoning Questions Level I
Question 1
If you were the nurse taking Mr. Quinland’s health history during his latest trip to the ED,

what would be your primary concerns?
Answer 1
The primary concerns would be increasing dyspnea at rest, no follow-up with a primary
health provider, and use of the ED for medical care.
Question 2
What nursing diagnoses are appropriate for Mr. Quinland at this time?
Answer 2
Activity Intolerance related to chronic obstructive pulmonary disease (COPD) is the
appropriate diagnosis.
Question 3
Is Mr. Quinland’s smoking the priority consideration at this time? Why or why not?
Answer 3
Smoking is the primary consideration, because it increases the rate of lung function decline
and disabling symptoms
Clinical Reasoning Questions Level II
Question 4
Refer to the exemplar on COPD in the module on Oxygenation: What signs/symptoms of
COPD does Mr. Quinland exhibit? What risk factors does he have?
Answer 4
Chronic dyspnea is one of the most common problems of patients with moderate to severe
COPD. Risk factors include smoking, age, and occupational exposure.
Question 5
Refer to the exemplar on Nicotine Use in the module on Addiction: Why/how does smoking
result in alterations such as chronic hypercapnia and COPD?
Answer 5
Patients with severe COPD with exacerbation are at increased risk for hypoxemia, oxygen
desaturation, and hypercapnia. Many patients have elements of both emphysema and
chronic bronchitis, and both diseases have chronic air flow limitations that are not reversible
and therefore classified as COPD. Decreased carbon dioxide elimination results in increased
carbon dioxide tension in arterial blood (hypercapnia) and leads to respiratory acidosis and
chronic respiratory failure.
Question 6
What patient teaching would you attempt to provide Mr. Quinland prior to discharge?
Answer 6

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MODULE 1: THE CONCEPT OF ACID–BASE BALANCE
Exemplar 1.A: Metabolic Acidosis
Nursing Care Plan (pp. 17–18)
Question 1
How does a history of laxative and diuretic abuse in the setting of an eating disorder
cause metabolic acidosis?
Answer 1
Metabolic acidosis is caused by excess acid or decrease bicarbonate in the body. The
use/abuse of laxatives can result in diarrhea which increases the excretion of
bicarbonates. Diuretics can lead to decreased fluid volume.
Question 2
How do electrolyte and renal dysfunction cause changes in cognition and mental status?
Answer 2
The kidneys are responsible for long-term acid–base balance. With renal dysfunction
there can be increased excretion of metabolic acids and subsequent increase in
bicarbonate excretion and changes in electrolyte status. Electrolyte loss or excess can
lead to changes in cognition and mental status with confusion and possibly stupor or
coma.
Question 3
Normal hematocrit is 3 times the hemoglobin. Why is the hematocrit elevated?
Answer 3
With fluid volume deficit, the hematocrit rises artificially and the hemoglobin drops.
Note: Fluid volume deficits may be the result of excessive renal loss of water and
sodium from diuretic abuse or chronic abuse of laxatives.

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In severe dehydration, the volume of fluid drops and the number of RBCs per volume of
fluid rises. This is the most common cause of a high hematocrit. With adequate fluid intake,
the hematocrit returns to normal.
Question 6
What safety precautions should be implemented for Mr. James at this time?
Answer 6
Safety is the number one priority at all times. Safely monitor all activity levels for the
patient. When the patient is critically ill, he will be on bedrest. It is important to turn the
patient and to provide oral care and good hygiene.

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Question 5
What precautions should the nurse implement for the patient with metabolic acidosis to
prevent potential injury?
Answer 5
This patient may need to be restrained secondary to confusion for his safety. Make sure
side rails are up because of drowsiness and confusion. Patient may need to be turned on
side to prevent aspiration if there is nausea or vomiting.
Question 6
The patient with metabolic acidosis becomes confused and disoriented. What nursing care
should the nurse provide to this patient to maintain safety?
Answer 6
This patient may need

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Question 5
The patient with metabolic alkalosis becomes confused and disoriented. What strategies
will help promote communication with this patient?
Answer 5
Confusion may be related to dehydration, electrolyte disturbances, and cardiac arrhythmias.
The nurse should address the underlying factors and ensure patient safety. Interventions to
promote orientation to the environment should be initiated, including calling the patient by
name, introducing yourself, and telling the patient what you are doing.

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MODULE 1: THE CONCEPT OF ACID–BASE BALANCE
Exemplar 1.C: Respiratory Acidosis
Reflect
Reread Clinical Example C on page 12. Mr. Quinland’s vitals were as follows: TO 38.4°C
(101.1°F); HR 125 bpm; R 32/min; BP 150/90 mmHg. ABGs (arterial blood gases) were
immediately drawn by the respiratory therapist. ABG values were pH 7.32; PaCO2 50
mmHg; PaO2 78 mmHg; HCO3 45 mEq/L. The nurse auscultated decreased breath sounds
with scattered rhonchi in the right upper and middle lobes. The patient was placed on a 2-L
nasal cannula, and pulse oximetry was 90%. The respiratory therapist administered a
nebulizer treatment, and a chest x-ray was performed.
The hospital admitted Mr. Quinland overnight. The chest x-ray revealed hyperinflation
with flattened diaphragm and right lobular bacterial pneumonia. He was started on
antibiotics and remained on low-flow oxygen. A pulmonologist consult was ordered, and
Mr. Quinland was discharged after seeing the pulmonary physician. He was scheduled for
pulmonary function studies after the pneumonia cleared. The discharge medications were
antibiotics, respiratory inhalers, and oxygen. Discharge teaching included information on
smoking cessation.
Unfortunately, Mr. Quinland was not able to wean to room air, and he was discharged on a
2-L nasal cannula with oximetry of 91%. Home care services have been arranged for Mr.
Quinland.
Question 1
What is the interpretation of the ABG results?
Answer 1
ABG results indicate respiratory acidosis.
Question 2
How is the patient compensating for the acidosis?
Answer 2
Compensation for respiratory acidosis occurs through renal retention of bicarbonate.
Question 3
How can you determine if this is a chronic problem?
Answer 3
Chronic obstructive pulmonary disease (COPD) patients hold onto bicarbonate to
compensate for acidosis.
Question 4
Mr. Quinland’s pO

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Nursing: A Concept-Based Approach to Learning, Volume I, 3rd Edition Solution Manual

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