Chapter 13: Acid-Base Balance

Test Bank
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.

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.

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.

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
b. 1 and 2
c. 1, 2, and 3
d. 1 and 3

ANS: D
Isohydric buffering and ventilation are the two major mechanisms responsible for maintaining a stable pH in the
face of massive CO2 production.

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.

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 Test bank 13-2
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.

7. By comparison, how much fixed acid is produced in any given period compared to the volatile acid CO2?
a. about the same amount
b. less fixed than volatile
c. more fixed than volatile

ANS: B
Compared with daily CO2 production, fixed acid production is small, averaging only about 50 to 70
milliequivalents (mEq) per day.

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]).

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.

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.

11. Which of the following are components of the body's nonbicarbonate buffer system?
1. hemoglobin

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 Test bank 13-3
2. plasma proteins
3. organic phosphates
4. inorganic phosphates
a. 1, 2, and 3
b. 2 and 4
c. 3 only
d. 1, 2, 3, and 4

ANS: D
The nonbicarbonate buffer system consists mainly of phosphates and proteins, including hemoglobin.

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.

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.

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.

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.

16. Which buffer system has the greatest capacity?

a. bicarbonate
b. hemoglobin
c. phosphates
d. plasma proteins

ANS: A

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 Test bank 13-4
Bicarbonate buffers have the greatest buffering capacity because they function in an open system.

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.

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
b. 2 and 3
c. 4 only
d. 1 and 2

ANS: D
[H+] = (KA ´ [H2CO3])/[ HCO3-]
Thus, [H+] is determined by the ratio between undissociated acid molecules [H2CO3] and base anions [HCO3-].

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.

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.

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).

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22. Of the nonbicarbonate buffer systems, which one is the most important?
a. hemoglobin
b. inorganic phosphate
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.

23. Which of the following systems is primarily responsible for the buffering of fixed acids?
a. ammonia
b. HCO3-
c. Hb
d. phosphates

ANS: B
Most of the added fixed acid is buffered by HCO3- because ventilation continually pulls the reaction to the left.

24. Which of the following acts as the “first-line” or immediate defense against the accumulation of H + ions?
a. blood buffer systems
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.

25. Acid excretion is shared by which of the following organ systems?

1. kidneys
2. liver
3. lungs
a. 3 only
b. 1 and 3
c. 2 only
d. 1, 2, and 3

ANS: B
The lungs and kidneys are the primary acid-excreting organs.

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
b. 2 and 3
c. 4 only
d. 1, 2, 3, and 4

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.

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 Test bank 13-6
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

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.

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.

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
c. 2 only
d. 2 and 3

ANS: A
Both HCO3- ions and Na+ ions are reabsorbed with water whenever H+ ions are secreted into the tubular filtrate.

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.

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32. What affect does hyperventilation have on HCO3- recovery in the kidneys?
a. less H+ excretion, greater HCO3- loss
b. no affect 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 13-3), the ratio of HCO 3- 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.

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.

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
b. 1 and 3
c. 2
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.

35. Which of the following is FALSE about the relationship between chloride (Cl-) and bicarbonate HCO3- in acid-
base balance?
a. For each Cl ion excreted into the urine, the blood gains an HCO3 ion.
b. Blood Cl- and HCO3- ion levels are reciprocally related.
c. People with chronically high CO2 tend to have low blood Cl- levels.
d. Activation of the NH3 buffer system enhances Cl- gain and HCO3 loss.

ANS: D
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 13-5 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.

36. Which organ system maintains the normal level of HCO3- at 24 mEq/L?
a. liver
b. lung
c. renal

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 Test bank 13-8
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.

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.

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 µ kidneys/lungs.S

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
b. 3
c. 1 and 3
d. 2 and 4

ANS: C
An increase in [HCO3-] or a decrease in PCO2 will raise the pH, leading to alkalemia.

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
b. 1, 2, and 3
c. 3 only
d. 1 and 2

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

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 Test bank 13-9
PaCO2 = 35 to 45 mm Hg
[HCO3-] = 22 to 26 mEq/L
Alkalemia is defined as a blood pH greater than 7.45.

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.

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.

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.

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.

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.

46. A patient has a bicarbonate concentration of 36 mEq and a PCO2 of 60 mm Hg. What is the approximate pH?

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 Test bank 13-10
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.

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.

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 about 27 to 28 mmol/L.
c. HCO3- will fall to about 20 to 21 mmol/L.
d. HCO3- will rise to about 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 1mEq/L for every 10mm Hg increase in PCO2 higher than
40 mm Hg.

49. A patient has a pH of 7.49. What would this define?

a. acidosis
b. alkalosis
c. not sufficient information
d. normal acid-base status

ANS: B
If the pH is greater than 7.45, a state of alkalosis exists.

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..

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?

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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.

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.

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 HCO3-], 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.

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
b. 2 and 3
c. 2 and 4
d. 1, 3, and 4

ANS: A
This completely compensated respiratory acidosis is characterized by the same originally observed high PaCO 2, 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.

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. central nervous system depression
a. 1, 2, 3, and 4
b. 3
c. 2, 3, and 4
d. 2 and 4

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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.

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
b. 1 and 3
c. 3 only
d. 2, 3, and IV4

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 CO2 hydration reaction on [HCO3-].

57. Correction of acute respiratory acidosis is accomplished by which of the following?

a. increasing HCO3- reabsorption
b. increasing alveolar ventilation
c. decreasing HCO3- reabsorption
d. 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.

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 (less than 35 mm Hg) and raises the arterial pH (greater
than 7.45) produces respiratory alkalosis.

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 PO 2
(hypoxemia).

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

1. anxiety
2. central nervous system depression
3. hypoxemia

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4. pain
a. 1, 2, and 3
b. 1, 3, and 4
c. 1 and 4
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.

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.

62. Which of the following is NOT a clinical sign of acute respiratory alkalosis?
a. convulsions
b. depressed reflexes
c. dizziness
d. paresthesia

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.

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 13-3).

64. 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.

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 Test bank 13-14
65. A patient who has fully compensated respiratory acidosis becomes severely hypoxic. If her lungs are not too
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 PaCO 2 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 PaCO 2,
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.

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
b. 1 and 2
c. 1, 2, and 3
d. 1 and 3

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.

67. Discounting K+, 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.

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 increased.
a. 2 and 3
b. 1 and 2
c. 1 and 3
d. 1, 2, and 3

ANS: D
An increased anion gap (greater than 14 mEq/L) is caused by metabolic acidosis in which fixed acids accumulate
in the body.

69. What explains the lack of an increased anion gap seen in metabolic acidosis caused by HCO3- 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

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 Test bank 13-15
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 13-7, C).

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
b. 2 and 4
c. 2, 3, and 4
d. 1, 3, and 4

ANS: C
Box 13-5 summarizes causes of anion gap and nonanion gap metabolic acidosis.

71. Which of the following is NOT a cause of hyperchloremic metabolic acidosis?

a. hyperalimentation
b. methanol intoxication
c. severe diarrhea
d. NH4Cl administration

ANS: B
Box 13-5 summarizes causes of anion gap and nonanion gap metabolic acidosis.

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.

73. A patient with Kussmaul's respirations most likely has:

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.

74. What is the treatment for severe metabolic acidosis?

a. charcoal
b. insulin
c. mechanical ventilation
d. NaHCO3- infusion

ANS: D
In cases of severe metabolic acidosis, intravenous infusion of sodium bicarbonate (NaHCO 3-) may be indicated.

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

a. gain of buffer base

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 Test bank 13-16
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.

76. Which of the following is NOT a cause of metabolic alkalosis?

a. diuretics
b. hyperkalemia
c. hypochloremia
d. vomiting

ANS: B
The causes of metabolic alkalosis are summarized in Box 13-6.

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

a. gastric suction
b. hypochloremia
c. hypokalemia
d. vomiting

ANS: A
Often, metabolic alkalosis is iatrogenic, resulting from the use of diuretics, low-salt diets, and gastric drainage.

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.

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 (CO 2 retention).

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.

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 Test bank 13-17
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.

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.

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.

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.

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

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 Test bank 13-18
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
uncompensated respiratory acidosis.

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.

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.

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
c. 2 and 3
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.

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 (Hb; g/dL)
c. Henderson-Hasselbalch equation
d. standard bicarbonate

ANS: D

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 Test bank 13-19
To eliminate the influence of the hydration reaction on plasma bicarbonate concentration, some laboratories
report standard bicarbonate.

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” (greater than +2 mEq/L) indicates a gain of base or loss of acid from
nonrespiratory causes. A “negative BE” (less than –2 mEq/L) indicates a loss of base or a gain of acid from
nonrespiratory causes.

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.

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.

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.

94. Why is Stewart’s strong ion approach to acid-base balance not used clinically instead of the Henderson-
Hasselbalch equation?
a. Clinically, it is unwieldy and overly complex.
b. Its conceptualization of the role of HCO3- is inaccurate.
c. It is so close conceptually that there is no need to change.

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 Test bank 13-20
d. Theoretically, it is inferior to the H-H equation.

ANS: A
Clinicians generally agree that the complex nature of the equations involved in Stewart’s strong ion approach
make this method unwieldy.
Plugging the ABG values supplied into the H-H equation results in a pH of exactly 7.35 indicating the accuracy
of this gas.

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 = 7.35, 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

96. 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.

97. A patient has a blood gas result of: pH 7.29, PaCO2 of 60 mmHg, 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
c. 2 and 3
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.

98. 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.

99. 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

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 Test bank 13-21
4. Accompanied by Cl- gain
a. 1, 3, and 4
b. 1 and 3
c. 3 only
d. 2, 3, and 4

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.

100. 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
b. 1 and 3
c. 3 only
d. 2, 3, and 4

ANS: A
First, the patient’s pH must be categorized. The patient’s pH is below the range of 7.35-7.45, which indicates
acidemia. Secondly, respiratory involvement must be determined. The PaCO 2 is well below the normal range of
35-45 mmHg, 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 PaCO 2 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 22-26 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

101. A 31 year old man suffering from food poisoning is having severe vomiting for the last two days. His blood gas
and serum electrolyte analyses revealed the following: pH of 7.60, PaCO2 of 49 mmHg, 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
b. 2 and 4
c. 3 only
d. 2, 3, and 4

ANS: B

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Test bank 13-22
The patient’s pH is well above the normal range of 7.35-7.45, so the pH is indicating alkalemia. Respiratory
involvement shows the PaCO2 is slightly above normal range of 35-45 mmHg, 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 22-26
mEq/L. Given the pH is indicating alkalemia, this elevated HCO3- is 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.

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