Chapter 14 - Acid-Base Balance

Kacmarek et al.: Egan’s Fundamentals of Respiratory Care, 11th Edition

MULTIPLE CHOICE

1. The primary goal of acid-base homeostasis is to maintain which of the following?

a. Normal HCO3–
b. Normal PCO2
c. Normal pH
d. Normal PO2
ANS: C
Acid-base balance refers to physiological mechanisms that keep the H+ ion concentration of
body fluids in a range compatible with life.

DIF: Recall REF: p. 286 OBJ: 1

2. What is the normal arterial blood pH range?

a. 7.25 to 7.35
b. 7.35 to 7.45
c. 7.45 to 7.55
d. 7.55 to 7.65
ANS: B
To sustain life, the body must maintain the pH of fluids within a narrow range, from 7.35 to
7.45.

DIF: Recall REF: p. 294 OBJ: 1

3. Which of the following is a volatile acid of physiologic significance?

a. Hydrochloric
b. Carbonic
c. Phosphoric
d. Lactic
ANS: B
The only volatile acid of physiologic significance in the body is carbonic acid (H2CO3), which
is in equilibrium with dissolved CO2.

DIF: Recall REF: p. 286 OBJ: 1

4. What are the major mechanisms responsible for maintaining a stable pH despite massive CO 2
production?
1. Isohydric buffering
2. Gastrointestinal secretion
3. Pulmonary ventilation
a. 2 and 3 only
b. 1 and 2 only
c. 1, 2, and 3
d. 1 and 3 only
 ANS: D
Isohydric buffering and ventilation are the two major mechanisms responsible for maintaining
a stable pH in the face of massive CO2 production.

DIF: Application REF: p. 286 OBJ: 1

5. Fixed acids are produced primarily from the catabolism of which of the following?
a. Carbohydrates
b. Fats
c. Proteins
d. Simple sugars
ANS: C
Catabolism of proteins continually produces fixed (nonvolatile) acids such as sulfuric and
phosphoric acids.

DIF: Recall REF: p. 286 OBJ: 1

6. What is the primary buffer system for fixed acids?

a. Cl–
b. HCO3–
c. Phosphate
d. Plasma proteins
ANS: B
The H+ of fixed acids can be buffered by HCO3– ions and converted to CO2 and H2O (see the
previous reaction); the CO2 thus formed is eliminated in exhaled gas.

DIF: Recall REF: p. 289 OBJ: 1

7. By comparison, how much fixed acid is produced in any given period compared to the volatile
acid CO2?
a. Approximately the same amount
b. Less fixed than volatile
c. More fixed than volatile
d. CO2 is not a volatile acid
ANS: B
Compared with daily CO2 production, fixed acid production is small, averaging only about 50
to 70 mEq/day.

DIF: Recall REF: p. 286 OBJ: 1

8. Which of the following statements about the equilibrium constant of an acid is true?
a. The equilibrium constant of a weak acid is large.
b. The equilibrium constant of a strong acid is small.
c. The equilibrium constant of a weak acid is small.
d. The more an acid ionizes, the smaller is the equilibrium constant.
ANS: C
 The KA is small because the H2CO3 concentration is quite large with respect to the numerator
of reaction (3). The value of KA is always the same for H2CO3 at equilibrium, regardless of
the initial concentration of H2CO3. A strong acid, such as HCl, has a large KA because the
denominator [HCl] is extremely small, compared with the numerator ([H+]  [Cl]).

DIF: Recall REF: p. 286 OBJ: 2

9. A solution that resists large changes in pH upon addition of an acid or a base best describes
which of the following?
a. Acid-base excretor
b. Buffer solution
c. Catabolic regulator
d. Homeostatic control
ANS: B
A buffer solution resists changes in pH when an acid or a base is added to it.

DIF: Recall REF: p. 287 OBJ: 3

10. When a strong acid is added to the bicarbonate buffer system, what is the result?
a. Strong base and neutral salt
b. Strong acid and neutral salt
c. Weak acid and neutral salt
d. Weak acid and basic salt
ANS: C
If hydrogen chloride, a strong acid, is added to the H2CO3/NaHCO3 buffer solution, HCO3–
ions react with the added H+ ions to form weaker carbonic acid molecules and a neutral salt:
HCl + H2CO3/Na+HCO3– 2H2CO3 + NaCl
The strong acidity of HCl is converted to the relatively weak acidity of H2CO3, preventing a
large decrease in pH.

DIF: Recall REF: p. 287 OBJ: 3

11. Which of the following are components of the body’s nonbicarbonate buffer system?
1. Hemoglobin
2. Plasma proteins
3. Organic phosphates
4. Inorganic phosphates
a. 1, 2, and 3 only
b. 2 and 4 only
c. 3 only
d. 1, 2, 3, and 4
ANS: D
The nonbicarbonate buffer system consists mainly of phosphates and proteins, including
hemoglobin.

DIF: Recall REF: p. 287 OBJ: 3

12. What is the sum of all blood buffers in 1 L of blood?

a. Buffer base
 b. Base excess
c. Standard bicarbonate
d. Base deficit
ANS: A
The blood buffer base is the sum of bicarbonate and nonbicarbonate bases measured in
mmol/L of blood.

DIF: Recall REF: p. 287 OBJ: 3

13. Why is the bicarbonate buffer system considered an open buffer system?
a. As the major blood and body buffer system, it is open by definition.
b. It operates only in the extracellular fluid, avoiding cell closure.
c. Its acid (carbonic acid) is converted to CO2 and removed.
d. Its chemical reactions occur very quickly.
ANS: C
The bicarbonate system is called an open buffer system because H2CO3 is in equilibrium with
dissolved CO2, which is readily removed by ventilation.

DIF: Recall REF: p. 287 OBJ: 4

14. Why is a buffer system such as phosphate considered a closed system?

a. All the components remain in the system.
b. It has limited utility in buffering acids.
c. Its ability to buffer volatile acids is incomplete.
d. Once its buffer level is established, it will never change.
ANS: A
A nonbicarbonate buffer system is called a closed buffer system because all the components of
acid-base reactions remain in the system.

DIF: Recall REF: p. 287 OBJ: 4

15. What factor would limit the ability of the H2CO3/HCO3– buffer system to perform efficiently?
a. Temperature rise of more than 3° C
b. Inadequate amount of 2,3-DPG in the blood
c. Increased production of nonvolatile acids
d. Lungs failing to excrete adequate levels of CO2
ANS: D
For example, volatile acid (H2CO3) accumulates only if ventilation cannot eliminate CO2 fast
enough to keep up with the body’s CO2 production.

DIF: Recall REF: p. 287 OBJ: 4

16. Which buffer system has the greatest capacity?

a. Bicarbonate
b. Hemoglobin
c. Phosphates
d. Plasma proteins
ANS: A
 Bicarbonate buffers have the greatest buffering capacity because they function in an open
system.

DIF: Recall REF: p. 287 OBJ: 4

17. What effect does hyperventilation have on the closed buffer systems?
a. It causes them to bind with more H+.
b. It causes them to release more H+.
c. It has no effect on them at all.
d. It increases the affinity of the closed buffer system.
ANS: B
Increased ventilation increases the CO2 removal rate, causing nonbicarbonate buffers to
release H+ ions. Decreased ventilation ultimately causes nonbicarbonate buffers to accept
more H+ ions.

DIF: Recall REF: pp. 287-288 OBJ: 4

18. [H+] can be determined by the use of which factors?

1. HCO3–
2. H2CO3
3. Inorganic phosphorus
4. PaO2
a. 1, 2, and 3 only
b. 2 and 3 only
c. 4 only
d. 1 and 2 only
ANS: D
[H+] = (KA  [H2CO3])/[HCO3–]
Thus, [H+] is determined by the ratio between undissociated acid molecules [H2CO3] and base
anions [HCO3–].

DIF: Recall REF: p. 288 OBJ: 4

19. A patient has a PCO2 of 80 mm Hg. What is the concentration of dissolved CO2 (in mmol/L)
in the blood?
a. 1.2 mmol/L
b. 2.4 mmol/L
c. 24 mmol/L
d. 40 mmol/L
ANS: B
Because dissolved CO2 (PCO2  0.03) is in equilibrium with and directly proportional to
blood [H2CO3], and because blood PCO2 is more easily measured than [H2CO3], dissolved
CO2 is used in the denominator of the Henderson-Hasselbalch equation.

DIF: Application REF: p. 288 OBJ: 4

20. Of what use is the Henderson-Hasselbalch equation for a clinician?

a. It can guide therapeutic decision for critically ill patients.
b. It establishes the baseline values for buffer enhancement treatments.
 c. Given H2CO3 and CO2 values, the pH can be computed.
d. It allows validation of the reported values on a blood gas report.
ANS: D
The Henderson-Hasselbalch equation is useful for checking a clinical blood gas report to see
if the pH, PCO2, and [HCO3] values are compatible with one another.

DIF: Recall REF: pp. 288-289 OBJ: 5

21. What drives the bicarbonate buffer systems enormous ability to buffer acids?
a. The fact that H2CO3 is a strong buffer
b. The Henderson-Hasselbalch equation
c. The large amounts of 2,3-DPG in red blood cells
d. Ventilation continually removing CO2 from system
ANS: D
This allows HCO3– to continue buffering H+ as long as ventilation continues. Hypothetically,
this buffering activity can continue until all body sources of HCO3– are used up in binding H+
(i.e., the aforementioned reaction is continually pulled to the left because ventilation
continually removes CO2).

DIF: Recall REF: pp. 289-290 OBJ: 6

22. Of the nonbicarbonate buffer systems, which one is the most important?
a. Hemoglobin
b. Inorganic phosphates
c. Organic phosphates
d. Plasma proteins
ANS: A
The nonbicarbonate buffers in the blood. Of these, hemoglobin (Hb) is the most important
because it is the most abundant.

DIF: Recall REF: p. 290 OBJ: 6

23. Which of the following systems is primarily responsible for the buffering of fixed acids?
a. Ammonia
b. HCO3–
c. Hb
d. Phosphate
ANS: B
Most of the added fixed acid is buffered by HCO3– because ventilation continually pulls the
reaction to the left.

DIF: Recall REF: p. 290 OBJ: 6

24. Which of the following acts as the “first-line” or immediate defense against the accumulation
of H+ ions?
a. Blood buffer system
b. GI tract
c. Renal system
 d. Respiratory system
ANS: A
Bicarbonate and nonbicarbonate buffer systems are the immediate defense against the
accumulation of H+ ions.

DIF: Recall REF: p. 295 OBJ: 6

25. Which of the following organ systems assist in acid excretion?

1. Kidneys
2. Liver
3. Lungs
a. 3 only
b. 1 and 3 only
c. 2 only
d. 1, 2, and 3
ANS: B
The lungs and kidneys are the primary acid-excreting organs.

DIF: Recall REF: p. 290 OBJ: 6

26. In regard to acid excretion by the body, which of the following statements are true?
1. If one system fails, the other can help compensate.
2. The kidneys can only remove fixed acids.
3. The kidneys can quickly remove acid.
4. The lungs can quickly remove acid.
a. 1, 2, and 4 only
b. 2 and 3 only
c. 4 only
d. 1 and 4 only
ANS: A
Bicarbonate buffers effectively buffer the H+ originating from fixed acid, converting it to
H2CO3 and, in turn, to CO2 and H2O. By eliminating the CO2, the lungs can rapidly remove
large quantities of fixed acid from the blood. The kidneys also remove fixed acids, but at a
relatively slow pace. In healthy individuals, the acid excretion mechanisms of lungs and
kidneys are delicately balanced. In diseased individuals, failure of one system can be partially
offset by a compensatory response of the other.

DIF: Recall REF: p. 289 OBJ: 6

27. The majority of the acid the body produces in a day is excreted through the lungs as CO2.
What happens to the H+ ions?
a. They are bound to Hb.
b. They bind to phosphate.
c. They form carbamino compounds.
d. They bind to an OH-forming H2O.
ANS: D
 The CO2 excretion of the lungs does not actually remove H+ ions from the body. Instead, the
chemical reaction that breaks down H2CO3 to form CO2 binds H+ ions in the harmless water
molecule:
H+ + HCO3– H2CO3 H2O + CO2

DIF: Recall REF: p. 290 OBJ: 6

28. Which organ system actually excretes H+ from the body?

a. Kidneys
b. Liver
c. Lungs
d. Spleen
ANS: A
The kidneys physically remove H+ from the body.

DIF: Recall REF: p. 290 OBJ: 6

29. If the blood PCO2 is high, the kidneys will do which of the following?
a. Excrete more H+ and reabsorb more HCO3–.
b. Excrete less H+ and reabsorb more HCO3–.
c. Excrete less H+ and reabsorb less HCO3–.
d. Excrete more H+ and reabsorb less HCO3–.
ANS: A
If the blood PCO2 is high, creating high levels of H2CO3, then the kidneys excrete greater
amounts of H+ and reabsorb all of the tubule filtrate’s HCO3– back into the blood.

DIF: Recall REF: pp. 290-291 OBJ: 6

30. Normally which of the following occur when the kidneys eliminate H+?
1. Sodium ions (and water) are reabsorbed.
2. HCO3– is reabsorbed in proportion to the H+ excreted.
3. Bicarbonate buffer capacity is restored.
a. 1, 2, and 3
b. 1 and 3 only
c. 2 only
d. 2 and 3 only
ANS: A
Both HCO3– ions and Na+ ions are reabsorbed with water whenever H+ ions are secreted into
the tubular filtrate.

DIF: Recall REF: pp. 291-292 OBJ: 6

31. What is the role of carbonic anhydrase in the kidneys?

a. It drives the recovery of HCO3– and excretion of H+.
b. It is the catalyst for the hamburger phenomenon.
c. It promotes the excretion of CO2 in the urine.
d. It promotes the loss of fluids in congestive heart failure.
ANS: A
 The HCO3– ions in the filtrate react with the H+ ions secreted by the tubular cells. The
resulting carbonic acid breaks down into CO2 and water. Because CO2 is extremely diffusible
through biological membranes, it diffuses instantly into the tubule cell. There, CO2 reacts
rapidly with water in the presence of carbonic anhydrase, rapidly forming HCO3– and H+. The
HCO3– ion diffuses back into the blood. Thus, the reabsorbed HCO3– ion is not the same
HCO3– ion that existed in the tubular fluid. If the tubule cells secrete sufficient H+, all HCO3–
in the tubular fluid is reabsorbed in this manner.

DIF: Recall REF: p. 292 OBJ: 6

32. What effect does hyperventilation have on HCO3– recovery in the kidneys?
a. Less H+ excretion, greater HCO3– loss
b. No effect as these involve two independent systems.
c. Vicious cycle of worsening alkalemia as hyperventilation stimulates increased
HCO3– retention.
d. Escalating retention of other buffer bases along with HCO3–.
ANS: A
If blood CO2 is low, as is the case in a state of hyperventilation (see Figure 14-3), the ratio of
HCO3– ions to dissolved CO2 molecules increases. Consequently, the renal filtrate has more
HCO3– ions than H+ ions. Because HCO3– cannot be reabsorbed without first reacting with H+,
the excess HCO3– ions are excreted in the urine, carrying with them positive ions in the filtrate
such as Na+ or K+. Therefore, the net effect of secreting fewer H+ ions is to increase the
quantity of HCO3– (base) lost in the urine.

DIF: Recall REF: p. 292 OBJ: 6

33. What is the limiting factor for H+ excretion in the renal tubules?
a. Excessive amounts of Cl–
b. Excessive amounts of HCO3–
c. Insufficient buffers
d. Insufficient sodium
ANS: C
When filtrate pH falls to 4.5, H+ secretion stops. Buffers in the tubular fluid are essential for
the secretion and elimination of excess H+ ions in acidotic states.

DIF: Recall REF: p. 292 OBJ: 7

34. Which of the following mechanisms helps to eliminate excess H+ via the kidneys?
1. Reabsorption of HCO3–
2. Phosphate buffering
3. Ammonia buffering
a. 2 and 3 only
b. 1 and 3 only
c. 2 only
d. 1, 2, and 3
ANS: D
After all available HCO3– ions react with H+ ions, the remaining H+ ions react with two other
filtrate buffers, phosphate and ammonia, as illustrated in Figures 13-4 and 13-5.
 DIF: Recall REF: p. 292 OBJ: 7

35. Which of the following is/are true about the relationship between chloride (Cl –) and
bicarbonate HCO3– in acid-base balance?
1. For each Cl– ion excreted into the urine, the blood gains an HCO3– ion.
2. Blood Cl– and HCO3– ion levels are reciprocally related.
3. People with chronically high CO2 tend to have low blood Cl– levels.
4. Activation of the NH3 buffer system enhances Cl– gain and HCO3 loss.
a. 2 and 3 only
b. 1, 2, and 3 only
c. 2 only
d. 2, 3, and 4 only
ANS: B
The net effect of ammonia buffer activity is to cause more bicarbonate to be reabsorbed into
the blood, counteracting the acidic state of the blood. Figure 14-5 shows that when a Cl– ion is
excreted in combination with an ammonium ion, the blood gains an HCO3– ion. Thus, blood
Cl– and HCO3– ion concentrations are reciprocally related (i.e., when one is high, the other is
low). This explains why people with chronically high blood PCO2 tend to have low blood Cl
concentrations. Activation of the ammonia buffer system enhances Cl– loss and HCO3– gain.

DIF: Recall REF: p. 294 OBJ: 7

36. Which organ system maintains the normal level of HCO3– at 24 mEq/L?
a. Liver
b. Lung
c. Renal
d. Spleen
ANS: C
Normally, the kidneys maintain an arterial bicarbonate concentration of approximately 24
mEq/L, whereas lung ventilation maintains an arterial PCO2 of approximately 40 mm Hg.

DIF: Recall REF: p. 294 OBJ: 7

37. According to the Henderson-Hasselbalch equation, the pH of the blood will be normal as long
as the ratio of HCO3– to dissolved CO2 is which of the following?
a. 10:1
b. 20:1
c. 24:1
d. 30:1
ANS: B
Note that the pH is determined by the ratio of [HCO3–] to dissolved CO2, rather than by the
absolute values of these components. As long as the ratio of HCO3– buffer to dissolved CO2 is
20:1, the pH is normal, or 7.40.

DIF: Recall REF: p. 294 OBJ: 7

38. The numerator of the Henderson-Hasselbalch (H-H) equation (HCO3–) relates to which of the
following?
 a. Blood concentration of nonbicarbonate buffers
b. Excretion of volatile acid by the lungs
c. Renal buffering and excretion of fixed acids
d. Respiratory component of acid-base balance
ANS: C
Because the kidneys control blood [HCO3–] and the lungs control blood CO2 levels, the H-H
equation can be conceptually rewritten as follows:
PH  kidneys/lungs.

DIF: Recall REF: p. 294 OBJ: 7

39. According to the Henderson-Hasselbalch equation, the blood pH will rise (alkalemia) under
which of the following conditions?
1. The buffer capacity increases.
2. The volatile acid (CO2) increases.
3. The volatile acid (CO2) decreases.
4. The buffer capacity decreases.
a. 1 only
b. 3 only
c. 1 and 3 only
d. 2 and 4 only
ANS: C
An increase in [HCO3–] or a decrease in PCO2 will raise the pH, leading to alkalemia.

DIF: Recall REF: p. 294 OBJ: 7

40. When does a state of alkalemia exist?

1. The HCO3–/CO2 ratio exceeds 20:1.
2. The blood pH exceeds 7.45.
3. The blood PCO2 exceeds 54 mm Hg.
a. 2 and 3 only
b. 1, 2, and 3
c. 3 only
d. 1 and 2 only
ANS: D
An increase in [HCO3–] or a decrease in PCO2 will raise the pH, leading to alkalemia. This
produces a [HCO3–]/(PCO2  0.03) ratio greater than 20:1 (e.g., 25:1). A decreased [HCO3–] or
an increased PCO2 decreases the pH, leading to acidemia. This produces a [HCO3–]/(PCO2 
0.03) ratio less than 20:1 (e.g., 15:1). The normal ranges for arterial pH, PCO2, and [HCO3–]
are as follows:
pH = 7.35 to 7.45
PaCO2 = 35 to 45 mm Hg
[HCO3–] = 22 to 26 mEq/L
Alkalemia is defined as a blood pH greater than 7.45.

DIF: Recall REF: p. 294 OBJ: 7

41. What is the primary chemical event in respiratory acidosis?

 a. Decrease in blood CO2 levels
b. Decrease in blood HCO3– levels
c. Increase in blood CO2 levels
d. Increase in blood HCO3– levels
ANS: C
A high PaCO2 increases dissolved CO2, lowering the pH:
pH HCO3–/PaCO2
where means decreased, means no change, and means increased. Respiratory disturbances
causing acidemia are called respiratory acidosis.

DIF: Recall REF: p. 294 OBJ: 7

42. What is the primary chemical event in metabolic alkalosis?

a. Decrease in blood CO2 levels
b. Decrease in blood HCO3– levels
c. Increase in blood CO2 levels
d. Increase in blood HCO3– levels
ANS: D
Processes that increase arterial pH by losing fixed acid or gaining HCO3– produce a condition
called metabolic alkalosis.

DIF: Recall REF: p. 294 OBJ: 7

43. What is a normal response of the body to a failure in one component of the acid-base
regulatory mechanism?
a. Autoregulation
b. Compensation
c. Correction
d. Homeostasis
ANS: B
When any primary acid-base defect occurs, the body immediately initiates a compensatory
response.

DIF: Recall REF: p. 294 OBJ: 7

44. Compensation for respiratory acidosis occurs through which of the following?
a. Decrease in blood CO2 levels
b. Decrease in blood HCO3– levels
c. Increase in blood CO2 levels
d. Increase in blood HCO3– levels
ANS: D
For example, in hypoventilation (respiratory acidosis), the kidneys restore the pH toward
normal by reabsorbing HCO3– into the blood.

DIF: Recall REF: p. 295 OBJ: 7

45. Compensation for metabolic acidosis occurs through which of the following?
a. Increase in blood CO2 levels
 b. Decrease in blood CO2 levels
c. Decrease in blood HCO3– levels
d. Increase in blood HCO3– levels
ANS: B
If a nonrespiratory (metabolic) process lowers or raises [HCO3–], the lungs compensate by
hyperventilating (eliminating CO2) or hypoventilating (retaining CO2), restoring the pH to
near normal.

DIF: Recall REF: p. 295 OBJ: 7

46. A patient has a bicarbonate concentration of 36 mEq and a PCO2 of 60 mm Hg. What is the
approximate pH?
a. 7.2
b. 7.3
c. 7.4
d. 7.5
ANS: C
The kidneys compensate by retaining HCO3–, returning the plasma HCO3–/dissolved CO2 ratio
to almost 20:1. The conversion of PCO2 to mEq is done by multiplying by 0.03.
Thus 60  0.03 = 1.8. 36 to 1.8 is equal to a 20 to 1 ratio, thus the pH should be 7.40.

DIF: Application REF: p. 295 OBJ: 7

47. Which of the following accurately describes compensation for acid-base disorders?
a. Kidneys take hours to days to compensate for respiratory disorders.
b. Lungs take hours to days to compensate for metabolic disorders.
c. Renal compensation is always complete.
d. Respiratory compensation is always complete.
ANS: A
The lungs normally compensate quickly for metabolic acid-base defects because ventilation
can change the PaCO2 within seconds. The kidneys require more time to retain or excrete
significant amounts of HCO3–, and thus compensate for respiratory defects at a much slower
pace.

DIF: Recall REF: p. 295 OBJ: 7

48. A patient with a measured plasma HCO3– concentration of 24 mmol/L has an episode of acute
hypoventilation, with the PCO2 rising from 40 to 70 mm Hg. What do you predict will happen
acutely to the plasma HCO3– concentration?
a. HCO3– will remain unchanged.
b. HCO3– will rise to approximately 27 to 28 mmol/L.
c. HCO3– will fall to approximately 20 to 21 mmol/L.
d. HCO3– will rise to approximately 54 to 55 mmol/L.
ANS: B
In general, when the nonbicarbonate buffer concentration is normal and the PCO2 rise is acute,
the hydration reaction raises the plasma [HCO3–] approximately 1 mEq/L for every 10 mm Hg
increase in PCO2 higher than 40 mm Hg.
 DIF: Application REF: p. 295 OBJ: 7

49. A patient has a pH of 7.49. How would you describe this?

a. Acidemia
b. Alkalemia
c. Not sufficient information to determine
d. Normal acid-base status
ANS: B
Alkalemia is defined as a blood pH greater than 7.45. Acidemia is defined as a blood pH less
than 7.35.

DIF: Recall REF: p. 296 OBJ: 8

50. An increase in the H+ ion concentration [H+] of the blood due only to an increase in the arterial
PCO2 (hypercapnia) best describes which of the following?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: C
For example, if the pH was lower than 7.35 (denoting an acidosis) and the PaCO2 was higher
than 45 mm Hg, according to the H-H equation, the high PaCO2 would indeed lower the pH
(i.e., produce an acidosis). Therefore, the respiratory system is at least in part, if not entirely,
responsible for the acidosis.

DIF: Recall REF: p. 297 OBJ: 8

51. An ABG result shows the pH to be 7.56 and the HCO3- to be 23 mEq/L. Which of the
following is the most likely disorder?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
If HCO3– is in the normal range in the presence of alkalosis, then the alkalosis probably is of
respiratory origin.

DIF: Recall REF: p. 297 OBJ: 8

52. An ABG result shows pH of 7.35, PaCO2 of 30 mm Hg, and HCO3– of 18 mEq/L. Which of
the following is the patient’s most likely primary disorder?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: A
 In cases in which compensation has occurred, if the pH is on the acidic side of 7.40 (7.35 to
7.39), the component that would cause an acidosis (either increased PaCO2 or decreased
plasma HCO3–) is generally the primary cause of the original acid-base imbalance.

DIF: Application REF: p. 297 OBJ: 8

53. An ABG result shows pH of 7.35, PaCO2 of 30 mm Hg, and HCO3– of 18 mEq/L. What
compensatory measure has the body taken to at least partially compensate for the acid-base
disorder?
a. Blown off CO2
b. Retained HCO3–
c. Retained H+
d. Not enough information to determine
ANS: A
The patient has a compensated metabolic acidosis. This is characterized by a low HCO 3–, a pH
between 7.35 and 7.39, and a low PaCO2. The compensatory response (decreased PaCO2) has
restored the pH to the low normal range.

DIF: Application REF: p. 297 OBJ: 8

54. Which of the following clinical findings would you expect in a fully compensated respiratory
acidosis?
1. Elevated HCO3–
2. pH below 7.35
3. pH between 7.35 and 7.39
4. Elevated PO2
a. 1 and 3 only
b. 2 and 3 only
c. 2 and 4 only
d. 1, 3, and 4 only
ANS: A
This completely compensated respiratory acidosis is characterized by the same originally
observed high PaCO2, a pH that is now in the 7.35 to 7.39 range, and a plasma [HCO3–] that is
greater than it was before complete compensation took place.

DIF: Recall REF: p. 298 OBJ: 9

55. Causes of respiratory acidosis in patients with normal lungs include which of the following?
1. Neuromuscular disorders
2. Spinal cord trauma
3. Anesthesia
4. Use of incentive spirometry
a. 1, 2, and 3 only
b. 4 only
c. 2, 3, and 4 only
d. 1 and 3 only
ANS: A
 Any process in which alveolar ventilation fails to eliminate CO2 as rapidly as the body
produces it causes respiratory acidosis. This could occur in different ways. A person’s
ventilation may be decreased from a drug-induced central nervous system depression.

DIF: Recall REF: p. 298 OBJ: 9

56. In the face of uncompensated respiratory acidosis, which of the following blood gas
abnormalities would you expect to encounter?
1. Decreased pH
2. Increased HCO3–
3. Increased PCO2
4. Increased pH
a. 1, 2, and 4 only
b. 1 and 3 only
c. 3 only
d. 2, 3, and 4 only
ANS: B
If hypercapnia is uncompensated, respiratory acidosis occurs with a low pH, a high PaCO2,
and a normal or slightly high [HCO3–]. In this instance, the slightly high [HCO3–] is not a sign
that the kidneys have started compensatory activity; it merely reflects the effect of CO 2
hydration reaction on [HCO3–].

DIF: Recall REF: p. 298 OBJ: 9

57. How is acute respiratory acidosis accomplished?

a. By increasing HCO3– reabsorption
b. By increasing alveolar ventilation
c. By decreasing HCO3– reabsorption
d. By decreasing alveolar ventilation
ANS: B
The main goal in correcting respiratory acidosis is to improve alveolar ventilation. This may
entail various respiratory care modalities ranging from bronchial hygiene and lung expansion
techniques to endotracheal intubation and mechanical ventilation.

DIF: Recall REF: p. 298 OBJ: 9

58. A decrease in the H+ ion concentration [H+] of the blood caused by a low PaCO2 best describes
which of the following?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
Any physiologic process that lowers the arterial PCO2 (<35 mm Hg) and raises the arterial pH
(>7.45) produces respiratory alkalosis.

DIF: Recall REF: p. 298 OBJ: 9

59. What is the most common cause of respiratory alkalosis?

 a. Anxiety
b. Central nervous system depression
c. Hypoxemia
d. Pain
ANS: C
The most common cause of hyperventilation in patients with pulmonary disease is probably a
low arterial PO2 (hypoxemia).

DIF: Recall REF: p. 299 OBJ: 9

60. Which of the following are potential causes of respiratory alkalosis?

1. Anxiety
2. Central nervous system depression
3. Hypoxemia
4. Pain
a. 1, 2, and 3 only
b. 1, 3, and 4 only
c. 1 and 4 only
d. 1, 2, 3, and 4
ANS: B
Hypoxemia causes specialized neural structures to signal the brain, increasing ventilation (see
Chapter 14). Anxiety, fever, stimulatory drugs, pain, and central nervous system injuries are
possible causes of hyperventilation.

DIF: Recall REF: p. 299 OBJ: 9

61. What condition or treatment could cause iatrogenic respiratory alkalosis?

a. Central nervous system stimulation
b. Mechanical hyperventilation
c. Severe hypoxemia
d. Vagal stimulation
ANS: B
Hyperventilation and respiratory alkalosis also may be iatrogenically induced (induced by
medical treatment). Such hyperventilation is most commonly associated with overly
aggressive mechanical ventilation.

DIF: Recall REF: p. 299 OBJ: 9

62. Which of the following are signs and symptoms of acute respiratory alkalosis?
1. Convulsions
2. Depressed reflexes
3. Dizziness
4. Paresthesia
a. 1, 2, and 4 only
b. 1, 3, and 4 only
c. 2 and 4 only
d. 1, 2, 3, and 4
ANS: B
 An early sign of respiratory alkalosis is paresthesia (numbness or a tingling sensation in the
extremities). Severe hyperventilation is associated with dizziness, hyperactive reflexes, and
possibly tetanic convulsions.

DIF: Recall REF: p. 300 OBJ: 9

63. Compensation for respiratory alkalosis occurs through which of the following?
a. Renal excretion of H+
b. Renal excretion of HCO3–
c. Renal excretion of NH4+
d. Renal reabsorption of HCO3–
ANS: B
The kidneys compensate for respiratory alkalosis by excreting HCO3– in the urine (bicarbonate
diuresis; see Figure 14-3).

DIF: Recall REF: p. 300 OBJ: 9

64. In a patient with partially compensated respiratory alkalosis, which of the following blood gas
abnormalities would you expect to encounter?
1. Decreased pH
2. Decreased HCO3–
3. Decreased PCO2
4. Increased pH
a. 1, 2, and 4
b. 1 and 3
c. 3 only
d. 2, 3, and 4
ANS: D
Partly compensated respiratory alkalosis is characterized by a low PaCO2, a low [HCO3–], and
an alkaline pH—still not quite down in the normal range.

DIF: Recall REF: p. 300 OBJ: 9

65. A patient who has fully compensated respiratory acidosis becomes severely hypoxic. If her
lungs are not too severely compromised, what might her gases now appear to be?
a. Fully compensated metabolic acidosis
b. Fully compensated metabolic alkalosis
c. Fully compensated respiratory alkalosis
d. No change
ANS: B
Consider a patient with a compensated respiratory acidosis who has an arterial pH of 7.38, a
PaCO2 of 58 mm Hg, and an HCO3– of 33 mEq/L. If this patient becomes severely hypoxic,
the hypoxia may stimulate increased alveolar ventilation if lung mechanics are not too
severely deranged. This would acutely lower the PaCO2, possibly raising the pH to the
alkalotic side of normal. For example, the patient’s blood gas values might now be as follows:
pH of 7.44, PaCO2 of 50 mm Hg, and HCO3– of 33 mEq/L.

DIF: Application REF: p. 300 OBJ: 9

66. Metabolic acidosis may be caused by:
1. an increase in fixed (nonvolatile) acids.
2. an increase in blood carbon dioxide (CO2).
3. excessive loss of bicarbonate (HCO3–).
a. 1 only
b. 1 and 2 only
c. 1, 2, and 3
d. 1 and 3 only
ANS: D
Metabolic acidosis can occur in one of the following two ways: (1) fixed (nonvolatile) acid
accumulation in the blood or (2) an excessive loss of HCO3– from the body.

DIF: Recall REF: p. 300 OBJ: 9

67. What is a normal anion gap range?

a. 3 to 5 mEq/L
b. 6 to 8 mEq/L
c. 9 to 14 mEq/L
d. 24 to 26 mEq/L
ANS: C
A value of 140 mEq/L for Na+, 105 mEq/L for Cl, and 24 mEq/L for HCO3–, yielding an anion
gap of 11 mEq/L (140 mEq/L – [105 mEq/L + 24 mEq/L] = 11 mEq/L). The normal anion gap
range is 9 to 14 mEq/L.

DIF: Recall REF: p. 301 OBJ: 11

68. A patient has an anion gap of 21 mEq/L. Based on this information, what can you conclude?
1. There is an abnormal excess of unmeasured anions in the plasma.
2. The patient probably has metabolic acidosis.
3. The concentration of fixed acids is decreased.
a. 2 only
b. 1 and 2 only
c. 1 and 3 only
d. 3 only
ANS: B
An increased anion gap (>14 mEq/L) is caused by metabolic acidosis in which fixed acids
accumulate in the body.

DIF: Application REF: p. 301 OBJ: 11

69. What explains the lack of an increased anion gap seen in metabolic acidosis caused by HCO 3–
loss?
a. For each HCO3– ion lost, a Cl– ion is reabsorbed by the kidney.
b. For each HCO3– ion lost, the body produces another to replace it.
c. HCO3– is not a measured anion, so its loss does not affect the anion gap.
d. Replacement of HCO3– occurs by ammonia ions which are also anions.
ANS: A
 A metabolic acidosis caused by HCO3– loss from the body does not cause an increased anion
gap. Bicarbonate loss is accompanied by Cl– ion gain, which keeps the anion gap within
normal limits (Figure 14-7, C).

DIF: Recall REF: p. 301 OBJ: 11

70. What are some causes of metabolic acidosis with an increased anion gap?
1. Diarrhea
2. Ketoacidosis
3. Lactic acidosis
4. Renal failure
a. 2 and 3 only
b. 2 and 4 only
c. 2, 3, and 4 only
d. 1, 3, and 4 only
ANS: C
Box 14-5 summarizes causes of anion gap and nonanion gap metabolic acidosis.

DIF: Recall REF: p. 301 OBJ: 10 | 11

71. Which of the following is/are cause(s) of hyperchloremic metabolic acidosis?

1. Hyperalimentation
2. Methanol intoxication
3. Severe diarrhea
4. NH4Cl administration
a. 2 only
b. 1 and 4 only
c. 1, 3, and 4 only
d. 1, 2, 3, and 4
ANS: B
Box 14-5 summarizes causes of anion gap and nonanion gap metabolic acidosis.

DIF: Recall REF: p. 301 OBJ: 10 | 11

72. What is the main compensatory mechanism for metabolic acidosis?

a. Excretion of HCO3–
b. Hyperventilation
c. Hypoventilation
d. Retention of CO2
ANS: B
Hyperventilation is the main compensatory mechanism for metabolic acidosis. The increased
plasma [H+] of metabolic acidosis is buffered by plasma HCO3–, reducing the plasma [HCO3–],
and thus the pH. Uncompensated metabolic acidosis suggests that a ventilatory defect must
exist.

DIF: Recall REF: p. 302 OBJ: 9 | 10 | 11

73. In a patient with Kussmaul’s respirations, what acid-base disturbance would you expect to
see?
 a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: A
With severe diabetic ketoacidosis, a very deep, gasping type of breathing develops, called
Kussmaul’s respiration.

DIF: Recall REF: p. 302 OBJ: 9 | 11

74. What is the treatment for severe metabolic acidosis?

a. Charcoal
b. Insulin
c. Glucose
d. NaHCO3– infusion
ANS: D
In cases of severe metabolic acidosis, intravenous infusion of sodium bicarbonate (NaHCO3–)
may be indicated.

DIF: Recall REF: p. 302 OBJ: 9 | 11

75. Primary metabolic alkalosis is associated with which of the following?

a. Gain of buffer base
b. Gain in fixed acids
c. Low blood CO2 levels
d. Diabetic crisis
ANS: A
Metabolic alkalosis can occur in one of the following two ways: (1) loss of fixed acids or (2)
gain of blood buffer base.

DIF: Recall REF: p. 302 OBJ: 9 | 11

76. Which of the following is/are cause(s) of metabolic alkalosis?

1. Diuretics
2. Hyperkalemia
3. Hypochloremia
4. Vomiting
a. 1, 3, and 4 only
b. 2 and 3 only
c. 1, 2, and 4 only
d. 2 only
ANS: A
The causes of metabolic alkalosis are summarized in Box 14-6.

DIF: Recall REF: p. 303 OBJ: 9 | 11

77. What would be an example of an iatrogenic cause of metabolic alkalosis?

a. Gastric suction
 b. High-salt diet
c. Discontinuing the patient’s diuretics
d. Vomiting
ANS: A
Often, metabolic alkalosis is iatrogenic, resulting from the use of diuretics, low-salt diets, and
gastric drainage.

DIF: Recall REF: p. 303 OBJ: 9 | 11

78. What is the kidneys’ most important function?

a. Acid-base balance
b. Chloride maintenance
c. HCO3– maintenance
d. Sodium maintenance
ANS: D
The kidneys’ main job is to reabsorb sodium, not excrete it. For this reason, and because
sodium has a major role in maintaining fluid balance, the kidney places a greater priority on
reabsorbing Na+ than on maintaining Cl–, K+, or acid-base balance.

DIF: Recall REF: p. 303 OBJ: 9 | 11

79. What compensates for a metabolic alkalosis?

a. Hyperventilation
b. Hypoventilation
c. Renal excretion of HCO3–
d. Renal retention of H+
ANS: B
The expected compensatory response to metabolic alkalosis is hypoventilation (CO2
retention).

DIF: Recall REF: p. 304 OBJ: 9 | 11

80. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.43, PCO2 = 39 mm Hg, HCO3– = 25.1 mEq/L
a. Acid-base status within normal limits
b. Fully compensated metabolic acidosis
c. Fully compensated respiratory alkalosis
d. Partially compensated metabolic acidosis
ANS: A
As all the ABG values are within normal limits the gas must be normal.

DIF: Recall REF: pp. 296-297 OBJ: 9 | 11

81. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.62, PCO2 = 41 mm Hg, HCO3– = 40.9 mEq/L
a. Acute (uncompensated) metabolic alkalosis
b. Acute (uncompensated) respiratory alkalosis
c. Fully compensated metabolic alkalosis
 d. Partially compensated metabolic alkalosis
ANS: A
The patient is alkalotic (pH >7.35). This can be caused by an elevated HCO3– or a low PCO2.
In this question the HCO3– is elevated. If compensation were present the PCO2 would have to
be elevated. As it is normal, this is an uncompensated metabolic alkalosis.

DIF: Application REF: p. 303 OBJ: 9 | 11

82. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.43, PCO2 = 20 mm Hg, HCO3– = 12.6 mEq/L
a. Acute (uncompensated) respiratory alkalosis
b. Fully compensated metabolic acidosis
c. Fully compensated respiratory alkalosis
d. Partially compensated respiratory alkalosis
ANS: C
The patient’s pH is normal so either the gas is normal or fully compensated. As the PCO2 and
HCO3– are both low, a fully compensated state exists. As the pH is on the high side of normal
the fully compensated disorder would be alkalosis. This would be caused by a low PCO2 or a
high HCO3–. In this case a low PCO2. The low HCO3– is compensating for this respiratory
alkalosis.

DIF: Application REF: p. 295 OBJ: 9 | 11

83. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 6.89, PCO2 = 24 mm Hg, HCO3– = 4.7 mEq/L
a. Acute (uncompensated) metabolic acidosis
b. Acute (uncompensated) respiratory acidosis
c. Partially compensated metabolic acidosis
d. Partially compensated respiratory acidosis
ANS: C
The patient is acidotic (pH <7.35). This can be caused by an elevated PCO2 or a low HCO3–. In
this question the HCO3- is low. Partial compensation is present as the PCO2 is also low.

DIF: Application REF: p. 297 OBJ: 9 | 11

84. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.08, PCO2 = 39 mm Hg, HCO3– = 11.8 mEq/L
a. Acute metabolic acidosis
b. Acute respiratory acidosis
c. Partially compensated metabolic acidosis
d. Partially compensated respiratory acidosis
ANS: A
The patient is acidotic (pH <7.35). This can be caused by an elevated PCO2 or a HCO3– low. In
this question the HCO3– is low. If compensation were present the PCO2 would have to be
decreased. As it is normal this is an uncompensated metabolic acidosis. Remember that when
there is no compensation in this situation, it usually implies that there is a primary problem
with the respiratory system as well.
 DIF: Application REF: p. 297 OBJ: 9 | 11

85. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.28, PCO2 = 53 mm Hg, HCO3– = 25.8 mEq/L
a. Acute metabolic acidosis
b. Acute respiratory acidosis
c. Partially compensated metabolic acidosis
d. Partially compensated respiratory acidosis
ANS: B
The patient is acidotic (pH <7.35). This can be caused by an elevated PCO2 or a HCO3– low. In
this question the PCO2 is high. If compensation were present the HCO3– would have to be
increased. As it is normal this is an acute (uncompensated) respiratory acidosis.

DIF: Application REF: p. 297 OBJ: 9 | 11

86. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.38, PCO2 = 21 mm Hg, HCO3– = 11.7 mEq/L
a. Acute metabolic acidosis
b. Fully compensated metabolic acidosis
c. Partially compensated metabolic acidosis
d. Fully compensated respiratory alkalosis
ANS: B
The patient’s pH is normal so either the gas is normal or fully compensated. As the PCO2 and
HCO3– are both low, a fully compensated state exists. As the pH is on the low side of normal
the fully compensated disorder would be acidosis. This would be caused by a low HCO3– or a
high PCO2. In this case a low HCO3–. The low PCO2 is compensating for this metabolic
acidosis.

DIF: Application REF: p. 297 OBJ: 9 | 11

87. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.35, PCO2 = 68 mm Hg, HCO3– = 34.3 mEq/L
a. Acute respiratory acidosis
b. Combined metabolic and respiratory acidosis
c. Fully compensated respiratory acidosis
d. Fully compensated metabolic alkalosis
ANS: C
The patient’s pH is normal so either the gas is normal or fully compensated. As the PCO2 and
HCO3 are both high, a fully compensated state exists. As the pH is on the low side of normal
the fully compensated disorder would be acidosis. This would be caused by a low HCO3– or a
high PCO2– in this case a high PCO2. The high HCO3– is compensating for this respiratory
acidosis.

DIF: Application REF: p. 297 OBJ: 9 | 11

88. Correction of metabolic alkalosis may involve which of the following?

1. Restoring normal fluid volume
2. Administering acidifying agents
 3. Restoring normal K+ and Cl levels
a. 3 only
b. 1 and 2 only
c. 2 and 3 only
d. 1, 2, and 3
ANS: D
Correction of metabolic alkalosis is aimed at restoring normal fluid volume and electrolyte
concentrations, especially K+ and Cl levels. Inadequate fluid volume, especially if coupled
with hypochloremia, causes excessive secretion and loss of H+ and K+ ions because of the
great need to reabsorb Na+ ions. Thus, in treating this type of alkalosis, it is important to
supply adequate fluids containing Cl ions. If hypokalemia is a primary factor, then KCl is the
preferred corrective agent. In cases of severe metabolic alkalosis, acidifying agents, such as
dilute hydrochloric acid or ammonium chloride may be infused directly into a large central
vein.

DIF: Recall REF: p. 297 OBJ: 9 | 11 | 12

89. In order to eliminate the influence of PCO2 changes on plasma HCO3– concentrations, what
additional measures of the metabolic component of acid-base balance can be used?
a. HCO3–
b. Hemoglobin content
c. Henderson-Hasselbalch equation
d. Standard bicarbonate
ANS: D
To eliminate the influence of the hydration reaction on plasma bicarbonate concentration,
some laboratories report standard bicarbonate.

DIF: Recall REF: p. 304 OBJ: 9 | 11 | 12

90. What is the normal range for BE?

a. ±2 mEq/L
b. ±4 mEq/L
c. ±6 mEq/L
d. ±24 mEq/L
ANS: A
A normal BE is ±2 mEq/L. A “positive BE” (>+2 mEq/L) indicates a gain of base or loss of
acid from nonrespiratory causes. A “negative BE” (<2 mEq/L) indicates a loss of base or a
gain of acid from nonrespiratory causes.

DIF: Recall REF: p. 305 OBJ: 12

91. In acute respiratory acidosis, what would you expect the BE range to be?
a. –4 to –6 mEq/L
b. +2 to –2 mEq/L
c. +4 to +6 mEq/L
d. +22 to +26 mEq/L
ANS: B
 In cases of acute (uncompensated) respiratory acidosis, the BE commonly would be within the
normal range, indicating correctly that the disturbance is purely respiratory in origin.

DIF: Application REF: p. 305 OBJ: 12

92. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.62, PCO2 = 32 mm Hg, HCO3– = 29 mEq/L
a. Acute (uncompensated) metabolic alkalosis
b. Combined metabolic and respiratory alkalosis
c. Partially compensated metabolic alkalosis
d. Partially compensated respiratory acidosis
ANS: B
A combined disturbance is one in which both respiratory and metabolic disturbances exist,
which promote the same acid-base disturbance. For example, consider the following arterial
blood gas results: a pH value of 7.62, a PaCO2 value of 32 mm Hg, and an HCO3– value of 29
mEq/L. The pH indicates alkalemia, consistent with both the low PaCO2 and the elevated
HCO3–. This is a combined alkalosis, indicating that the patient has two primary acid-base
problems (i.e., respiratory and metabolic alkalosis combined). Therefore, compensation is not
possible.

DIF: Application REF: p. 306 OBJ: 12 | 13

93. Based on the following ABG results, what is the most likely acid-base diagnosis?
pH = 7.01, PCO2 = 71 mm Hg, HCO3– = 16.3 mEq/L
a. Acute metabolic acidosis
b. Acute respiratory acidosis
c. Combined respiratory and metabolic acidosis
d. Partially compensated respiratory acidosis
ANS: C
A combined disturbance is one in which both respiratory and metabolic disturbances exist,
which promote the same acid-base disturbance. For the following arterial blood gas results: a
pH value of 7.01, a PaCO2 value of 71 mm Hg, and an HCO3– value of 16.3 mEq/L. The pH
indicates acidemia, consistent with both the high PaCO2 and the decreased HCO3–. This is a
combined acidosis, indicating that the patient has two primary acid-base problems (i.e.,
respiratory and metabolic alkalosis combined). Therefore, compensation is not possible.

DIF: Application REF: p. 306 OBJ: 12

94. Using the Henderson-Hasselbalch equation, determine the accuracy of the gas below. To be
considered accurate, it must be within 0.03 pH unit.
pH = 7.35, PCO2 = 77 mm Hg, HCO3– = 41 mEq/L
a. This gas is completely accurate.
b. This gas is accurate as the calculated pH is 7.32.
c. This gas is accurate as the calculated pH is 7.38.
d. This gas is inaccurate according to the H-H equation.
ANS: A DIF: Application REF: p. 288 OBJ: 12
95. Using the Henderson-Hasselbalch equation, determine the accuracy of the gas below. To be
considered accurate, it must be within 0.03 pH unit.
pH = 7.22, PCO2 = 49 mm Hg, HCO3– = 20 mEq/L
a. This gas is completely accurate.
b. This gas is accurate as the calculated pH is 7.23.
c. This gas is accurate as the calculated pH is 7.20.
d. This gas is inaccurate according to the H-H equation.
ANS: B
Plugging the ABG values supplied into the H-H equation results in a pH of 7.33 which
indicate the gas is accurate as the value should be within 0.03 of the recorded pH.

DIF: Application REF: p. 288 OBJ: 12

96. A patient has a blood gas result of: pH 7.29, PaCO2 of 60 mm Hg, and a HCO3 of 18 mEq/L.
What is the blood gas indicating?
1. It is indicating a combined acidosis.
2. Patient has a primary respiratory and a primary metabolic disorder.
3. Compensation is not possible.
a. 3 only
b. 1 and 2 only
c. 2 and 3 only
d. 1, 2, and 3
ANS: D
A mixed acid-base disorder has two primary acid-base problems, which is indicated by the
low pH caused by a high PaCO2 and a low HCO3.

DIF: Application REF: p. 295 OBJ: 13

97. Approximately how much CO2 is removed daily by the lungs?

a. ~24,000 mmol/L of CO2
b. ~14,000 mmol/L of CO2
c. ~34,000 mmol/L of CO2
d. ~4,000 mmol/L of CO2
ANS: A
The lungs remove approximately 24,000 mmol/L of CO2 daily.

DIF: Recall REF: p. 286 OBJ: 6

98. A metabolic acidosis caused by HCO3 loss:

1. can be a result of ammonium chloride ingestion.
2. will cause an increased anion gap.
3. may be referred to as hyperchloremic acidosis.
4. accompanied by Cl– gain.
a. 1, 3, and 4 only
b. 1 and 3 only
c. 3 only
d. 2, 3, and 4 only
ANS: A
 Metabolic acidosis caused by a loss of bicarbonate can be caused by ammonium chloride
ingestion or severe diarrhea. As the body is losing the bicarbonate, the kidneys increase their
reabsorption of chloride ions which keeps the anion gap within normal limits. This type of
metabolic acidosis is sometimes referred to as hyperchloremic acidosis.

DIF: Application REF: p. 302 OBJ: 10

99. A 21-year-old woman in the emergency room is displaying rapid and deep, labored breathing.
Her room ABG reveals a pH of 7.25, PaCO2 of 28, HCO3– of 14 mEq/L, and a base excess of
–14 mEq/L. How would the respiratory therapist assess her acid-base condition?
1. Severe hyperventilation
2. Partially compensated metabolic acidosis
3. Compensatory response to the metabolic acidosis
4. Severe hypoventilation
a. 1, 2, and 3 only
b. 1 and 3 only
c. 3 only
d. 2, 3, and 4 only
ANS: A
First, the patient’s pH must be categorized. The patient’s pH is below the range of 7.35 to
7.45, which indicates acidemia. Second, respiratory involvement must be determined. The
PaCO2 is well below the normal range of 35 to 45 mm Hg, indicating severe hyperventilation.
By itself, this would cause alkalosis, but the presence of a low pH indicating acidemia, this
rules out the cause as primary respiratory alkalosis. The low PaCO2 is probably a
compensatory response to primary metabolic acidosis, although the response is insufficient to
restore pH to its normal range. Third, a determination of metabolic involvement must be
analyzed. The HCO3– is severely reduced below the normal range of 22 to 26 mEq/L. This
result is consistent with the low pH. In the presence of low pH and low PaCO2 and a low
HCO3– low indicates primary metabolic acidosis. This is also confirmed by the large BE value.
Finally, a confirmation of compensation must be made. The severe hyperventilation represents
a compensatory response to the primary metabolic acidosis, although compensation is far
from complete. Nevertheless, the pH level would be even lower if the PaCO2 were normal.

DIF: Analysis REF: p. 302 OBJ: 9 | 10 | 11

100. A 31-year-old man suffering from food poisoning is having severe vomiting for the last 2
days. His blood gas and serum electrolyte analyses revealed the following: pH of 7.60, PaCO2
of 49 mm Hg, an HCO3- of 47 mEq/L, a base excess (BE) of +20 mEq/L, a serum K+ of 2.5
mEq/L, and a serum of Cl– of 92 mEq/L. How would the respiratory therapist assess his acid-
base condition?
1. Severe hyperventilation
2. Metabolic alkalosis
3. Adequate compensatory response
4. Minimal hypoventilation
a. 1, 2, and 3 only
b. 2 and 4 only
c. 3 only
d. 2, 3, and 4 only
ANS: B
The patient’s pH is well above the normal range of 7.35 to 7.45, so the pH is indicating
alkalemia. Respiratory involvement shows the PaCO2 is slightly above normal range of 35 to
45 mm Hg, indicating mild hypoventilation. But, the pH does not represent respiratory
acidosis, and then the elevated PaCO2 may be a compensatory response to a primary
metabolic problem. The HCO3– is extremely higher than the normal range of 22 to 26 mEq/L.
Given the pH is indicating alkalemia, this elevated HCO3 represents metabolic alkalosis.
Another indication of metabolic alkalosis is confirmed by the large BE value. Plus, the low
serum K+ and Cl– values indicate hypokalemic and hypochloremic metabolic alkalosis. Even
though, PaCO2 is slightly elevated, compensation for metabolic alkalosis is minimal. This lack
of compensation is consistent with the presence of hypokalemic metabolic alkalosis.

DIF: Analysis REF: p. 306 OBJ: 9 | 11