The nurse identifies the diagnosis Risk for Impaired Gas Exchange to guide the care of a client with metabolic alkalosis. Which assessment data supports this nursing diagnosis?
Select all that apply.
A) Respiratory rate 8 per minute
B) Oxygen saturation 89%
C) Urine output 25 mL/hr
D) Restlessness and agitation
E) Weight loss of 3 kg overnight
Answer: A, B, D
Respiratory compensation for metabolic alkalosis depresses the respiratory rate and reduces the depth of breathing to promote carbon dioxide retention. The depressed respiratory drive associated with metabolic alkalosis can lead to hypoxemia and impaired oxygenation of tissues. Oxygen saturation levels of less than 90% indicate significant oxygenation problems. Changes in mental status or behavior may be early signs of hypoxia. Urine output less than 30 mL/hr would indicate Fluid Volume Deficit. Weight is used as an indicator of fluid balance. A rapid weight change would indicate Fluid Volume Deficit.
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Fill in the blank(s) with the appropriate word(s).