Arterial Blood Gases

Arterial blood gas analysis provides information on the following: 1] Oxygenation of blood through gas exchange in the lungs. 2] Carbon dioxide (CO2) elimination through respiration. 3] Acid-base balance or imbalance in extra-cellular fluid (ECF).

Normal Blood Gases

Arterial Venous pH 7.35 - 7.45 7.32 - 7.42 Not a gas, but a measurement of acidity or alkalinity, based on the hydrogen (H+) ions present. The pH of a solution is equal to the negative log of the hydrogen ion concentration in that solution: pH = - log [H+]. 80 to 100 mm 28 - 48 mm PaO2 Hg. Hg The partial pressure of oxygen that is dissolved in arterial blood. New Born Acceptable range 40-70 mm Hg. Elderly: Subtract 1 mm Hg from the minimal 80 mm Hg level for every year over 60 years of age: 80 - (age- 60) (Note: up to age 90) 22 to 26 19 to 25 HCO3 mEq/liter mEq/liter (2128 mEq/L) The calculated value of the amount of bicarbonate in the bloodstream. Not a blood gas but the anion of carbonic acid. PaCO2 35-45 mm Hg 38-52 mm Hg The amount of carbon dioxide dissolved in arterial blood. Measured. Partial pressure of arterial CO2. (Note: Large A= alveolor CO2). CO2 is called a volatile acid because it can combine reversibly with H2O to yield a strongly acidic H+ ion and a weak basic bicarbonate ion (HCO3 -) according to the following equation: CO2 + H2O <--- --> H+ + HCO3 2 to +2 mEq/liter B.E. Other

sources: normal reference range is between -5 to +3. The base excess indicates the amount of excess or insufficient level of bicarbonate in the system. (A negative base excess indicates a base deficit in the blood.) A negative base excess is equivalent to an acid excess. A value outside of the normal range (-2 to +2 mEq) suggests a metabolic cause for the abnormality. Calculated value. The base excess is defined as the amount of H+ ions that would be required to return the pH of the blood to 7.35 if the pCO2 were adjusted to normal. It can be estimated by the equation: Base excess = 0.93 (HCO3 - 24.4 + 14.8(pH 7.4)) Alternatively: Base excess = 0.93HCO3 + 13.77pH 124.58 A base excess > +3 = metabolic alkalosis a base excess < -3 = metabolic acidosis SaO2 95% to 100% 50 - 70% The arterial oxygen saturation.

Step by Step ABG Analysis Step One - Assessing pH

Look at pH and determine if it is acidotic (<7.35), normal (7.35 - 7.45), or alkalotic (> 7.45). pH is the best overall indicator in determining the acid-base status of the patient.

Step Two - Determine respiratory involvement

Review the PaCO2 to assess respiratory involvement [The lungs control the level of carbon dioxide in the arterial blood]. The PaCO2 must be evaluated in light of the arterial pH. That is, if the pH is abnormal, we then ask ourselves: would this observed PaCO2, by itself, cause this pH abnormality? For example, suppose that the pH is below 7.35 (denoting

acidosis) and the PaCO2 is above 45 mmHg. According to the Henderson-Hasselbalch equation, a high PaCO2 would indeed cause a low pH (i.e., acidosis). Therefore we know that the respiratory system is at least in part, if not entirely, responsible for the acidosis. On the other hand, if the pH is less than 7.35 and the PaCO2 is in the normal range, then we know that the acidosis must be of nonrespiratory (metabolic) origin. PaCO2: Normal: 35 - 45 mmHg (4.6 - 6 kPa) Respiratory acidosis: > 45 mmHg (> 6 kPa) Respiratory alkalosis: <35 mmHg (< 4.6 kPa)

Step Three - Determine metabolic involvement

Review the plasma [HCO3-] or B.E. (Base excess) to determine metabolic involvement (both controlled by non-respiratory factors.) Each of these components must be evaluated based on the current pH. If the pH is abnormal, we ask: would this observed [HCO3] by itself, cause this pH abnormality? For example, suppose that the pH is less that 7.35 (denoting acidosis) and the [HCO3-] is below 22 mEq/L. Indeed, according to the Henderson-Hasselbalch equation, the low [HCO3-] is consistent with acidosis. Thus, we know that non-respiratory factors are in part, if not entirely, responsible for the acidosis. If [HCO3-] were in the normal range in the presence of this acidosis, then we would know that the acidosis must be of respiratory origin. HCO3-------------------------Normal: 22 26 mEq/L Metabolic acidosis: <22 mEq/L Metabolic alkalosis: > 26 mEq/L [Standard Bicarbonate: Calculated value. Similar to the base excess. It is defined as the calculated bicarbonate concentration of the sample corrected to a PCO2 of 5.3kPa (40mmHg).

BE (Base Excess): -------------------------Normal: -2 to +2 mmol/L Metabolic acidosis: < -2 mmol/L Mild -4 to -6

Moderate -6 to -9 Marked Severe Metabolic mmol/L -9 to -13 to < -13 > +2

alkalosis: > +13 9 to 13

Severe Marked

Moderate 6 to 9 Mild 4 to 6

[Base excess (BE) is the mmol/L of base that needs to be removed to bring the pH back to normal when PCO2 is corrected to 5.3 kPa or 40 mmHg. During the calculation any change in pH due to the PCO2 of the sample is eliminated, therefore, the base excess reflects only the metabolic component of any disturbance of acid base balance.]

Step Four - Assess for compensation

Look at the pH, PaCO2, and B.E. / HCO3- to decide whether compensatory mechanisms are at work. Once the acid-base disorder is identified as respiratory or metabolic, we must look for the degree of compensation that may or may not be occurring. we know that the system not primarily responsible for the acid-base abnormality must assume the responsibility for returning the pH to the normal

range. This compensation may be complete (pH is brought into the normal range) or partial (pH is still out of the normal range but is in the process of moving toward the normal range.) In pure respiratory acidosis (high PaCO2, normal [HCO3-], and low pH) we would expect an eventual compensatory increase in plasma [HCO3-] that would work to restore the pH to normal. Similarly, we expect respiratory alkalosis to elicit an eventual compensatory decrease in plasma [HCO3-]. A pure metabolic acidosis (low [HCO3-], normal PaCO2, and a low pH) should elicit a compensatory decrease in PaCO2, and a pure metabolic alkalosis (high [HCO3-], normal PaCO2, and high pH) should cause a compensatory increase in PaCO2. All compensatory responses work to restore the pH to the normal range (7.35 7.45) [ See sample problems near the bottom of the page]

Step Five - Further analysis in cases of METABOLIC ACIDOSIS

Metabolic 1] Calculate the anion gap: Anion gap = Na+ - [CL- + HCO3-] Difference between calculated serum anions and cations. Based on the principle of electrical neutrality, the serum concentration of cations (positive ions) should equal the serum concentration of anions (negative ions). However, serum Na+ ion concentration is higher than the sum of serum Cl- and HCO3concentration. Na+ = CL- + HCO3- + unmeasured anions (gap). Normal anion gap: 12 mmol/L (10 - 14 mmol/L) acidosis:

2] Based on the anion gap and patient history review potential causes: Normal anion gap (hyperchloremic) metabolic acidosis: Normal anion gap acidosis: The most common causes of normal anion gap acidosis are GI or renal bicarbonate loss and impaired renal acid excretion. Normal anion gap metabolic acidosis is also called hyperchloremic acidosis, because instead of reabsorbing HCO3- with Na, the kidney reabsorbs Cl. Many GI secretions are rich in bicarbonate (eg, biliary, pancreatic, and intestinal fluids); loss from diarrhea, tube drainage, or fistulas can cause acidosis. In ureterosigmoidostomy (insertion of ureters into the sigmoid colon after obstruction or cystectomy), the colon secretes and loses bicarbonate in exchange for urinary Cl- and absorbs urinary ammonium, which dissociates into NH3+ and H+. Loss of HCO3 ions is accompanied by an increase in the serum Cl- concentration. The anion gap remains normal. Disease processes that can lead to normal anion gap (hyperchloremic) acidosis. Useful mnemonic (DURHAM): a) Diarrhea (HCO3and water is lost). b) Ureteral diversion: Urine from the ureter may be diverted to the sigmoid colon due to disease (uretero-colonic fistula) or after bladder surgery. In such an event urinary Cl- is absorbed by the colonic mucosa in exchange for HCO3-, thus increases the gastrointestinal loss of HCO3-. c) Renal tubular acidosis: dysfunctional renal tubular cells causes an inappropriate wastage of HCO3- and retention of Cl-. d) Hyperalimentation e) Acetazolamide f) Miscellaneous conditions: They include pancreatic fistula, cholestyramine, and calcium chloride (CaCl) ingestion, all of which can increase the gastrointestinal wastage of HCO3-. Increased anion gap metabolic acidosis High anion gap acidosis: The most common causes of a high anion gap metabolic acidosis are ketoacidosis, lactic acidosis, renal failure, and toxic ingestions. Renal failure causes anion gap acidosis by

decreased acid excretion and decreased bicarbonate reabsorption. Accumulation of sulfates, phosphates, urate, and hippurate accounts for the high anion gap. Toxins may have acidic metabolites or trigger lactic acidosis. In increased anion gap metabolic acidosis, the nonvolatile acids are organic or other inorganic acids (e.g., lactic acid, acetoacetic acid, formic acid, sulphuric acid). The anions of these acids are not Clions. The presence of these acid anions, which are not measured, will cause an increase in the anion gap. Useful mnemonic (MUD PILES): Methanol poisoning: Methanol is metabolized by alcohol dehydrogenase in the liver to formic acid. Uremia: In end-stage renal failure in which glomerular filtration rate falls below 1020 ml/min, acids from protein metabolism are not excreted and accumulate in blood. Diabetic ketoacidosis: incomplete oxidation of fatty acids causes a build up of beta-hydroxybutyric and acetoactic acids (ketoacids). Paraldehyde Ischemia: causes lactic poisoning. acidosis.

Lactic acidosis: Lactic acid is the end product of glucose breakdown if pyruvic acid, the end product of anaerobic glycolysis, is not oxidized to CO2 and H2O via the Tricarboxylic Acid Cycle. (Causes: hypoxia, ischemia, hypotension, sepsis). Ethylene glycol poisoning: Ethylene is metabolized by alcohol dehydrogenase to oxalic acid in the liver. Usually there is also a coexisting lactic acidosis. Salicylate poisoning

Causes of common acid-base disturbances: Metabolic acidosis (non-respiratory)

High anion gap. Renal HCO3Ketoacidosis (diabetes, Tubulointerstitial loss: renal

chronic malnutrition, Lactic Renal

alcoholism, disease. fasting). Renal tubular acidosis, acidosis. types 1, 2, 4. failure. Hyperparathyroidism.

Toxins metabolized to Ingestions acids: (acetazolamide, CaCl2, Methanol (formic acid) MgSO4) Others Ethylene glycol (oxalate) Paraldehyde (acetate, Hypoaldosteronism, chloracetate) Hyperkalemia Salicylates Parenteral infusion of arginine, lysine, NH4Cl. Toxins causing lactic Rapid NaCl infusion. acidosis Toluene (late). CO2 Cyanide Formulas Iron (Compensation): Isoniazid pCO2 decreases 1.2 for Toluene (initially high each mEq/L change in gap, subsequent HCO3 or excretion of metabolites pCO2 = last two digits of normalizes gap) pH Rhabdomyolysis (rare) Compensation Ventilation of the lungs Loss of base - increases through Normal anion gap stimulation of central (hyperchloremic acidosis) chemoreceptors (H+ ion GI HCO3- loss (diarrhea, receptors) in the medulla ileostomy, colostomy, and peripheral enteric fistulas, use of chemoreceptors in the ion-exchange resins) carotid and aortic bodies. Consequently PCO2 falls Ureterosigmoidostomy, below normal, and H+ ureteroileal conduit ion concentration falls. Respiratory compensation increases the acidic pH towards normal. The respiratory system responds to metabolic acidosis quickly and predictably by hyperventilation, so much so that pure metabolic acidosis is seldom seen.

Respiratory Alkalosis:
CNS disorders or lesions, Compensation:

hypoxia [Hypoxia-causing In the presence of conditions], pulmonary respiratory alkalosis the receptor stimulation kidneys compensate for (asthma, pneumonia, the increase in pH by pulmonary edema, PE), retaining H+ ions and Pulmonary vascular excreting HCO3 - ions. As disease, anxiety, fear, a result, pH falls towards pain, drugs (ASA, normal and HCO3 theophylline), liver concentration falls below failure, sepsis. normal. Renal compensation to Formulas respiratory alkalosis is a (Compensation): slow process and the pH - Acute: HCO3 decreases does not completely 0.22 for every mmHg return to normal. change in pCO2 Chronic: HCO3 decreases 0.5 for every mmHg change in pCO2

Metabolic alkalosis:

(non-resp)

Respiratory Acidosis:

Increase in base Central nervous Administration/ingestion depression: sedatives of HCO3- etc. Hypochloremia (HCO3 Neuromuscular disease retained). (Guillain-Barr, Diuretic therapy myasthenia gravis). Contraction of blood Trauma. volume. Severe restrictive Loss of fixed acid. disorders: scoliosis. Severe vomiting (loss of COPD. Acute airway H+). obstruction: choking etc. Nasogastric suction. CVA, pneumothorax, Hypokalemia - Potassium chest wall disorder, deficiency. tumor. Acute and chronic Corticosteroid lung disease. administration. Formulas Formulas (Compensation): (Compensation): - Acute: HCO3 increases pCO2 increases 0.6 for 0.1 for every mmHg each mmol/L change in change in pCO2 HCO3 Chronic: HCO3 Compensation: increases 0.35 for every The respiratory response mmHg change in pCO2 to metabolic alkalosis is

hypoventilation. PCO2 Compensation: In the rises above normal. presence of respiratory Respiratory compensation acidosis the kidneys to metabolic alkalosis is compensate for the fall in variable and pH by excreting H+ ions unpredictable. It is and retaining HCO3 unlikely that a conscious ions. As a result, pH rises patient breathing towards normal and spontaneously will HCO3 - concentration hypoventilate to a PCO2 rises above normal. Renal > 7.3 kPa (55 mmHg) to compensation (also called compensate for metabolic metabolic compensation) alkalosis. to respiratory acidosis is a slow process. Compensation is not obvious for several hours and takes 4 days to complete.

Sample Problems - Arterial Blood Gases

Respiratory alkalosis (chronic alveolar hyperventilation) Respiratory acidosis. Chronic ventilation failure Uncompensated metabolic alkalosis (Respiratory acidosis. acute ventilation failure uncompensated metabolic alkalosis pH: PaCO2: HCO3: BE: pH: PaCO2: HCO3: BE: pH: PaCO2: HCO3: BE: pH: PaCO2: HCO3: BE: pH: PaCO2: HCO3: BE: 7.44 24 16 -6 7.38 76 42 +14 7.56 44 38 +14 7.26 56 24 -4 7.56 40 34 +11

Respiratory pH: 7.44 alkalosis (chronic PaCO2: 26

alveolar hyperventilation) Respiratory acidosis. Chronic failure

HCO3: BE:

18 -4 7.40 56 34 +7 7.44 20 16 -7 7.24 36 14 -13 7.52 28 22 +1

pH: PaCO2: HCO3: ventilation BE: pH: PaCO2: HCO3: BE: pH: PaCO2: HCO3: BE: pH: PaCO2: HCO3: BE:

Respiratory alkalosis. Chronic alveolar hyperventilation Uncompensated metabolic acidosis Respiratory alkalosis (acute alveolar hyperventilation)

Dx - heroin overdose. Breathing - shallow, slow. Acute Respiratory ABGs: Acidosis pH: 7.30 PaCO2: 55 mm/Hg HCO3-: 27 mEq/L Hx/Dx: 73yo, emphysema, labored breathing at rest. Chronic Respiratory ABGs: Acidosis pH: 7.36 PaCO2: 64 mmHg HCO3-: 35 mEq/L Hx/Dx: 77yo, anxiety, psychosomatic origin. Rapid breathing and Acute Respiratory slurred speech. Alkalosis ABGs: pH: 7.57 PaCO2: 23 mmHg HCO3-: 21 mEq/L Compensated Respiratory Alkalosis Persistent bacterial pneumonia. Mild cyanosis and labored breathing.

ABGs: pH: 7.44 PaCO2: 26 mmHg HCO3-: 17 mEq/L PaO2: 53 mmHg 80 yo with heart disease. RX: diuretic ABGs: pH: 7.58 PaCO2: 48 mmHg HCO3-: 44 mEq/L BE: + 19 mEq/L Serum CL- 95 mEq/L

Metabolic Alkalosis

client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals not given privacy. Exercise must be limited and supervised. 4. A client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk? a. "Are you sure you want to kill yourself?" b. "I know if my husband left me, I'd want to kill myself. Is that what you think?" c. "How do you think you would kill yourself?" d. "Why don't you just look at the positives in your life?" RATIONALE: To determine if a client is at risk for suicide, ask, "How do you think you would kill yourself?" If the client has a plan, she may be closer to carrying out the act. Option 1 requires a yes-or-no response and is selflimiting. In option 2, the nurse is telling the client what to think and feel. Option 4 dismisses the client's feelings 5. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include: a. dilated pupils and slurred speech. b. rapid speech and agitation. c. dilated pupils and agitation. d. euphoria and constricted pupils. RATIONALE: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils. 6. The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include: a. turning on the lights and opening the windows so that the client doesn't feel crowded. b. leaving the client alone.

c. staying with the client and speaking in short sentences. d. turning on stereo music. RATIONALE: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client's anxiety. 7. The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for: a. a depressed client. b. a manic client. c. a suicidal client. d. an anxious client. RATIONALE: Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, anxious, or suicidal clients don't physically or mentally test the limits of the caregiver. 8. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is: a. highly important or famous. b. being persecuted. c. connected to events unrelated to oneself. d. responsible for the evil in the world. RATIONALE: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world. 9. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include: a. hyperalertness and sleep disturbances. b. memory loss of traumatic event and somatic distress. c. feelings of hostility and violent behavior. d. sudden behavioral changes and anorexia. RATIONALE: Signs and symptoms of posttraumatic stress disorder include hyperalertness, sleep disturbances, exaggerated startle, survival guilt, and memory impairment. Also, the client relives the traumatic event through dreams and recollections. Hostility, violent behavior, and anorexia aren't usual signs or symptoms of posttraumatic stress disorder 10. The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include: a. offering high-calorie meals and strongly encouraging the client to finish all food. b. insisting that the client remain active throughout the day so that he'll sleep at night. c. allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits. d. listening attentively with a neutr

d. perceptual disorders.

RATIONALE: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics 15. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? a. Aggressive behavior b. Paranoid thoughts c. Emotional affect d. Independence needs RATIONALE: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships 16. The nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client? a. Assigning him to group activities b. Reducing his stimulation c. Assisting him with self-care d. Helping him express his feelings RATIONALE: Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these clients aren't able to express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control 17. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: a. avoid shopping for large amounts of food. b. control eating impulses. c. identify anxiety-causing situations. d. eat only three meals per day. RATIONALE: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment 18. The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development? a. Has perceptions based on reality b. Assumes responsibility for actions

c. Generates new levels of awareness d. Has maximum ability to solve problems and learn new skills RATIONALE: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30 19. A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium? a. Sexual dysfunction b. Constipation c. Polyuria d. Seizures RATIONALE: Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. Sexual dysfunction isn't a common adverse effect of lithium; it's more common with sedatives and tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. Constipation can occur with other psychiatric drugs, such as antipsychotic drugs. Seizures may be a later sign of lithium toxicity 20. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: a. tension and irritability. b. slow pulse. c. hypotension. d. constipation. RATIONALE: An amphetamine is a nervous system stimulant that's subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect 21. During a shift report, the nurse learns that she'll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as: a. barbiturates. b. antianxiety drugs. c. depressants. d. amphetamines. RATIONALE: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still

26. The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: a. benztropine (Cogentin). b. diphenhydramine (Benadryl). c. propranolol (Inderal). d. haloperidol (Haldol). RATIONALE: Benztropine, trihexyphenidyl, or amantadine is prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms 27. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? a. Monthly blood tests will be necessary. b. Report a sore throat or fever to the physician immediately. c. Blood pressure must be monitored for hypertension. d. Stop the medication when symptoms subside. RATIONALE: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/ml, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician 28. A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? a. Calcium b. Sodium c. Chloride d. Potassium RATIONALE: Lithium is chemically similar to sodium. When sodium levels are reduced, such as from sweating or diuresis, lithium is reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions, but sodium is most important to the absorption of lithium 29. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? a. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you." b. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." c. "You're wrong. Nobody is trying to kill you." d. "A foreign government is trying to kill you? Please tell me more about it."

RATIONALE: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions 30. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which finding should alert the nurse that the client is experiencing pseudoparkinsonism? a. Restlessness, difficulty sitting still, pacing b. Involuntary rolling of the eyes c. Tremors, shuffling gait, masklike face d. Extremity and neck spasms, facial grimacing, jerky movements RATIONALE: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and pill rolling. Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing