A nurse is caring for a child whose respirations are shallow and marked by a prolonged expiratory phase

The nurse auscultates wheezes and poor air movement bilaterally. The child's respiratory rate is 26 breaths per minute, and the oxygen saturation is 89%. What does the nurse suspect?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis


ANS: C
Respiratory acidosis results from retention of CO2 secondary to hypoventilation caused either by depression of the medullary respiratory center in the central nervous system (CNS) or by a pathologic lung condition, such as asthma. This child has shallow respirations with evidence of airway obstruction and poor ventilation. Metabolic acidosis occurs in chronic renal failure, loss of bicarbonate with severe diarrhea, metabolic disorders, and ingestion of acids such as salicylates; hyperventilation is a compensatory mechanism. Metabolic alkalosis is usually caused by excessive loss of gastric acid or by ingestion of alkalinizing salts; hypoventilation is a compensatory mechanism. Respiratory alkalosis is produced by hyperventilation and can occur in any condition that increases the respiratory rate and depth.

Nursing

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