Page 277 - Saunders Comprehensive Review For NCLEX-RN

When the client experiences an acid-base

imbalance, monitor the potassium level closely,
because the potassium moves in or out of the cells
in an attempt to maintain acid-base balance. The
resulting hypokalemia or hyperkalemia predisposes
the client to associated complications.
III. Respiratory Acidosis
A. Description: The total concentration of buffer base is lower than
normal, with a relative increase in hydrogen ion concentration;
thus, a greater number of hydrogen ions is circulating in the blood
than can be absorbed by the buffer system.

B. Causes (Box 9-1)

1. Respiratory acidosis is caused by primary defects in
the function of the lungs or changes in normal
respiratory patterns.
2. Any condition that causes an obstruction of the airway
leading to hypoventilation or depresses the
respiratory system can cause respiratory acidosis.

C. Assessment (Table 9-1)

For any acid-base imbalance, it is important to closely monitor the client’s level

of consciousness, use protective measures to ensure safety, and monitor electrolyte
levels and follow-up ABG test results.
D. Interventions
1. Monitor for signs of respiratory distress.
2. Administer O as prescribed.
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3. Place the client in a semi-Fowler’s position.
4. Encourage and assist the client to turn, cough, and
deep breathe.
5. Encourage hydration to thin secretions.
6. Reduce restlessness by improving ventilation rather
than by administering tranquilizers, sedatives, or
opioids, because these medications further depress
respirations.
7. Prepare to administer respiratory treatments as
prescribed; suction the client’s airway, if necessary.
8. Prepare for endotracheal intubation and mechanical
ventilation if CO levels rise above 50 mm Hg and
2
signs of acute respiratory distress are present.

If the client has a condition that causes an obstruction of the

airway or depresses the respiratory system, monitor the client for

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