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Concept 1 Acid-Base Balance
About Acid-Base Balance
1) A patient is brought to the emergency department after passing out in a local department store.
The patient has been fasting and has ketones in the urine. Which acid-base imbalance would the
nurse expect to assess in this patient?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
Answer: 3
Explanation: 3. A patient who is fasting is at risk for development of metabolic acidosis. The
body recognizes fasting as starvation and begins to metabolize its own proteins into ketones,
which are metabolic acids. Starvation would not result in respiratory acidosis or alkalosis or in
metabolic alkalosis.
Nursing Process: Implementation
Patient Need: Physiological Integrity
Cognitive Level: Analyzing
Learning Outcome: 1. Summarize the structure and physiological processes of the acid-base
regulatory systems related to acid-base balance.
2) Which of the following risk factors exhibited by the patient presenting in the emergency
department would place the patient at risk for metabolic acidosis.? (Select all that apply.)
1. Chronic obstructive pulmonary disease
2. Hypovolemic shock
3. Pneumonia
4. Abdominal fistulas
5. Acute renal failure
Answer: 2, 4, 5
Explanation: Metabolic acidosis is rarely a primary disorder. It usually develops during the
course of another disease such as shock, presence of abdominal fistulas, which can cause excess
bicarbonate loss, and acute renal failure. Chronic obstructive pulmonary disease and pneumonia
places the patient at risk for respiratory acidosis with the increased retention of carbon dioxide in
the blood.
Cognitive Level: Applying
1
Copyright © 2013 Pearson Education, Inc.
Learning Outcome: 2. List factors affecting acid-base balance.
2
3) A child with acute asthma has a PaCO2 of 48 mmHga pH of 7.C1, and a normal H2CO3
blood-gas value. The nurse interprets this as which of the following?
Answer: 1
Explanation: 1. If the pH is decreased and the PaCO2 is increased with a normal H2CO3, it is
uncompensated respiratory acidosis. In addition, croup can be a disease process that causes
respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased
PaCO2, and normal H2CO3. Uncompensated metabolic acidosis has a decreased pH, normal
PaCO2, and normal H2CO3. Uncompensated metabolic alkalosis has an increased pH, normal
PaCO2, and increased H2CO3.
Learning Outcome: 3. Identify commonly occurring alterations in acid-base balance and their
related treatments.
4) The nurse is caring for a patient with renal failure. Which of the following breathing patterns,
if exhibited by this patient, often results in the development of metabolic acidosis?
1. Cheyne-Stokes
2. Biot's
3. Cluster
4. Kussmaul's
Answer: 4
Explanation: 4. Kussmaul's respirations are a type of hyperventilation that accompanies
metabolic acidosis. They represent the body's attempt to compensate for the acidosis by "blowing
off" carbon dioxide. Cheyne-Stokes respirations are commonly a result of congestive heart
failure, increased intracranial pressure, or drug overdose. Cluster and Biot's respirations are the
same and are often the result of central nervous system disorders.
Learning Outcome: 4. Explain common physical assessment procedures used to examine acid-
base health of patients across the life span.
3
5) A patient has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have
been ordered. Which of the tests will provide the most accurate indicator of the patient's acid-
base balance?
1. Bronchoscopy
2. Sputum studies
3. Pulse oximetry
4. Arterial blood gases (ABGs)
Answer: 4
Explanation: 4. ABGs are done to assess alterations in acid-base balance caused by respiratory
disorders, metabolic disorders, or both. A bronchoscopy provides visualization of internal
respiratory structures. Sputum studies can provide specific information about bacterial
organisms. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of
blood.
Learning Outcome: 5. Outline diagnostic and laboratory tests to determine the individual's
acid—base status.
6) The nurse is monitoring the urine specific gravity and pH on a child receiving chemotherapy.
The nurse knows that which of the following results indicates the child is both dehydrated and
acidotic?
1. Spec gravity 1.030; pH 6
2. Spec gravity 1.030; pH 7.5
3. Spec gravity 1.005; pH 6
4. Spec gravity 1.005; pH 7.53
Answer: 1
Explanation: 1. Because the breakdown of malignant cells releases intracellular components into
the blood and electrolyte imbalance causes metabolic acidosis, the urine specific gravity should
remain at less than 1.010 and the pH at 7 to 7.5. A specific gravity higher than 1.010 can mean
fluid intake is not high enough, and a pH of less than 7 means acidosis.
Learning Outcome: 6. Explain management of acid-base balance and prevention of imbalances.
4
7) The patient who was diagnosed with diabetes mellitus 1 year ago is hospitalized in diabetic
ketoacidosis after a religious fast. The patient tells the nurse, "I have fasted during this season
every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable
about this particular religion. Which of the actions by this nurse would be appropriate? (Select all
that apply)
1. Tell the patient that it is different now because of the diabetes.
2. Do some research into the meaning of fasting in this religion.
3. Ask family members of the same religion to discuss fasting with the patient.
4. Request a consult from a diabetes educator.
5. Stress the importance of promptly seeking care if signs of ketoacidosis occur in the future.
Answer: 2, 4, 5
Explanation: The diabetes educator should be contacted to work with the patient on strategies
that might allow the fasting to occur in a safe manner. Research into the meaning of fasting in
this religion would be educative for the nurse and an appropriate. Stressing the importance of
promptly seeking care when signs of ketoacidosis occur helps to promote the patients health and
is appropriate. Telling the patient that life is different now does not support religious beliefs
Asking the family to talk to the patient might help, but the diabetes educator would be able to
provide more direct and helpful information for the patient.
Patient Need: Psychosocial Integrity
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in acid-base
balance.
8) The patient is receiving sodium bicarbonate intravenously (IV) for correction of acidosis
secondary to diabetic coma. The nurse assesses the patient to be lethargic, confused and
breathing rapidly. What is the nurse's priority response to the situation?
1. Continue the infusion because the patient is still in acidosis and notify the physician.
2. Increase the rate of the infusion and continue to assess the patient for symptoms of acidosis.
3. Stop the infusion and notify the physician because the patient is in alkalosis.
4. Decrease the rate of the infusion and continue to assess the patient for symptoms of alkalosis.
Answer: 1
Explanation: 1. The patient receiving sodium bicarbonate is prone to alkalosis; monitor for
cyanosis, slow respirations, and irregular pulse. The patient's symptoms do not indicate alkalosis
so infusion should not be stopped. The patient continues to exhibit signs of acidosis; symptoms
of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid
respiration rate that indicates an attempt by the lungs to rid the body of excess acid and the
physician should be notified. The infusion should not be increased or decreased without a
practitioner order.
Learning Outcome: 8. Identify pharmacological interventions in caring for the individual with
alterations in acid—base balance.
5
Exemplar 1.1: Metabolic Acidosis
1) The nurse is analyzing the patient's arterial blood gas report which reveals a pH of 6.58. The
patient has just suffered a cardiac arrest. Which of the following consequences does the nurse
consider for this patient?
1. Decreased cardiac output
2. Increased myocardial contractility
3. Increase magnesium levels
4. Decreased free calcium in the ECT
Answer: 1
Explanation: 1. The nurse knows that severe acidosis (pH of 7.0 or less) depresses myocardial
contractility, which leads to decreased cardiac output. Acid-base imbalances also affect
electrolyte balance. In acidosis, potassium is retained as the kidney excretes excess hydrogen ion.
Excess hydrogen ions also enter the cells, displacing potassium from the intracellular space to
maintain the balance of cations and anions within the cells. The effect of both processes is to
increase serum potassium levels. Also in acidosis, calcium is released from its bonds with plasma
proteins, increasing the amount of ionized (free) calcium in the blood. Magnesium levels may
fall in acidosis.
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of metabolic acidosis.
2) The mother of a 1-month-old infant calls the nurse who works in the health clinic. The mother
is concerned because the infant has had vomiting and diarrhea for 2 days. The nurse knows that
this infant is at risk for metabolic acidosis. Which of the following is the priority nursing action?
1. Instruct the mother to bring the infant to the clinic for evaluation.
2. Instruct the mother to give the infant at least 2 ounces of juice every 2 hours.
3. Instruct the mother to measure the infant's urine output for 24 hours.
4. Instruct the mother to provide the infant with 50 mL of glucose water.
Answer: 1
Explanation: 1. Parents and caregivers need to be taught the seriousness of vomiting or diarrhea
in infants due to rapid fluid loss that can occur in this age group. They should also be taught the
importance of bringing an infant in this situation to health care providers for evaluation.
Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status,
nor is juice or glucose water the best choice of fluid. Simply monitoring the loss over the next 24
hours would increase the potential for the infant to become dehydrated.
Learning Outcome: 2. Identify risk factors associated with metabolic acidosis.
6
3) The nurse is assessing an African American patient whose cultural background is different
from the cultural background of the nurse. The patient has symptoms of metabolic acidosis.
Which of the following situations would illustrate stereotypical behavior on the nurse's part?
(Select all that apply.)
1. Making an assumption that all members of each culture are alike
2. Understanding that all culture members will have the same beliefs
3. Bringing previous negative information and experiences into this situation
4. Taking general knowledge from literature and applying it to the situation
Answer: 1, 2, 4
Explanation: The other options 1, 2, and 4 describe stereotypical behavior, which is assuming
that all members of a culture or ethnic group are alike. Option 2 describes prejudice. Prejudice is
a negative belief or preference that is generalized about a group, which leads to "prejudgment."
Prejudice occurs when the person making the judgment generalizes an experience of one
individual from a culture to all members of that group.
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across lifespan for individuals with metabolic acidosis.
4) The nurse is caring for a patient who has been admitted with persistent diarrhea lasting 3 days.
Which of the following are appropriate nursing diagnoses for this patient during the acute phase
illness? (Select all that apply).
1. Risk for Injury
2. Decreased Cardiac Output
3. Knowledge Deficit
4. Deficient Fluid Volume
5. Ineffective Airway Clearance
Answer: 1, 2
Explanation: Metabolic acidosis affects cardiac output by decreasing contractility, slowing the
heart rate, and increasing the risk for dysrhythmias. Appropriate nursing diagnoses during the
acute phase of illness are Risk for Injury and Decreased Cardiac Output. The patient may have a
knowledge deficit but this is not an appropriate nursing diagnosis during the acute phase of the
illness. The patient with metabolic acidosis will be at risk for developing an Excessive Fluid
Volume not a Deficient Fluid Volume. The patient with metabolic acidosis is not at risk for
Ineffective Airway Clearance.
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
metabolic acidosis.
7
5) The nurse is caring for a patient with metabolic acidosis. Which of the following are
appropriate goals for this patient? (Select all that apply.)
1. The patient will describe preventative measure for the underlying chronic illness.
2. pH will range from 7.25 to 7.35
3. The patient will maintain a respiratory rate of 30 or more.
4. The patient will maintain baseline cardiac rhythm.
5. The patient will take potassium supplements to increase potassium levels.
Answer: 1, 4
Explanation: Planning for the patient with metabolic acidosis involves identification and
treatment of the underlying cause and restoration and maintenance of acid-base balance. The
patient should be able to describe preventative measures for the underlying chronic illness that
cause the metabolic acidosis to occur and maintain the baseline cardiac rhythm. The pH should
be maintained between 7.35 to 7.45. The patient's respiratory rate should be within normal range
for age and condition. Taking a potassium supplement may cause hyperkalemia, which decreases
cardiac output and worsens metabolic acidosis.
Learning Outcome: 5. Create a plan of care for individuals with metabolic acidosis and their
family members.
6) The nurse is caring for a patient admitted with renal failure and metabolic acidosis. Which of
the following signs would indicate to the nurse that planned interventions to relieve the
metabolic acidosis have been effective?
1. Increased deep tendon reflexes
2. Respiratory rate of 38
3. Decreased respiratory depth
4. Palpitations
Answer: 3
Explanation: 3. The patient with metabolic acidosis will have an increased respiratory rate and
depth. A sign that care has been effective would include a decrease in the rate and depth of
respirations. An increased respiratory rate, as indicated by a respiratory rate of 38, would
indicate continued metabolic acidosis. Increased deep tendon reflexes and palpitations are not
associated with metabolic acidosis.
Learning Outcome: 6. Assess expected outcomes for an individual with metabolic acidosis.
8
7) The nurse is caring for the patient experiencing hypovolemic shock and metabolic acidosis.
Which of the following therapies would the nurse question if planned for this patient? (Select all
that apply)
1. Administration of sodium bicarbonate
2. Monitor ECG for conduction problems
3. Monitor weight on admission and discharge
4. Limit the intake of fluids
Answer: 3, 4
Explanation: The treatment for hypovolemic shock would include the administration of fluids,
not limiting fluids. Patients being treated for hypovolemia will require daily weights, not a
weight on admission and then discharge. Administering sodium bicarbonate and monitoring
ECGs are all appropriate for the patient with shock.
Learning Outcome: 7. Discuss therapies used in the collaborative care of an individual with
metabolic acidosis.
8) A patient with metabolic acidosis has been admitted to the unit from the emergency room. The
patient is experiencing confusion and weakness. Which of the following does the nurse
implement as a priority of care for this patient?
1. Administer sodium bicarbonate.
2. Protect the patient from injury.
3. Give the patient skin care.
4. Place the patient in a high-Fowler's position.
Answer: 2
Explanation: 2. The patient with metabolic acidosis may have symptoms of drowsiness,
lethargy, confusion, and weakness. A priority of care would be preventing injury to the patient.
Medication administration is a physician order. Skin care would not be a priority on admission.
The high-Fowler's position would not be the safest position for the confused patient.
Learning Outcome: 8. Employ evidence-based caring interventions for an individual with
metabolic acidosis
9
Exemplar 1.2: Metabolic Alkalosis
1) The patient has been vomiting for several days. The nurse knows that the patient is at risk for
metabolic alkalosis because gastric sections have which of the following characteristics?
1. Gastric secretions are acidic.
2. Gastric secretions are alkaline.
3. Gastric secretions are green in color.
4. Gastric secretions have a foul smell.
Answer: 1
Explanation: 1. Metabolic alkalosis due to loss of hydrogen ions and usually occurs because of
vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost
through vomiting or gastric suction, the alkalinity of body fluids increases. This increased
alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys
as chloride is depleted. Gastric secretions are now alkaline. The color and odor of gastric
secretions have no influence on the development of metabolic acidosis.
direct and indirect causes of metabolic alkalosis.
2) The nurse is caring for a patient who has been admitted to the hospital for congestive heart
failure. Which of the following data collected during the nursing assessment indicates that the
patient is at risk for metabolic alkalosis? (Select all that apply)
1. The patient takes furosemide (Lasix) daily.
2. The patient takes a baby aspirin once daily.
3. The patient frequently uses calcium carbonate (Tums®) for acid indigestion.
4. The patient takes metformin daily.
Answer: 1, 3
Explanation: Excessive use of calcium carbonate and daily use of furosemide can cause
metabolic alkalosis. Use of metformin is not associated with alkalosis. Overuse of aspirin can be
associated with metabolic acidosis.
Learning Outcome: 2. Identify the risk factors associated with metabolic alkalosis.
10
3) An Asian-American adolescent is hospitalized following several days of vomiting following
food poisoning. The nurse is planning to include which of the following points when teaching the
patient's family at discharge? (Select all that apply.)
1. Signs and symptoms of metabolic alkalosis
2. Nutritional patterns of the adolescent
3. Proper food handling techniques
4. Immunizations for the adolescent
5. Normal laboratory values of the patient
Answer: 1, 3
Explanation: The family of anyone experiencing prolonged vomiting should be taught the signs
and symptoms of metabolic alkalosis. In this case, the nurse would include teaching about proper
methods of food handling to prevent further episodes of food poisoning. Food patterns of the
adolescent are not the precipitating factor of the food poisoning, nor would immunizations
prevent this disease. Unless the family asks, it is not necessary to teach normal laboratory
findings.
Patient Need: Health Promotion and Maintenance
across the lifespan for individuals with metabolic alkalosis.
4) The nurse is planning care for the patient who has been admitted with metabolic alkalosis.
Which of the following are appropriate nursing diagnoses for this patient during the acute phase
of the illness? (Select all that apply).
1. Deficient Fluid Volume
2. Risk for Impaired Gas Exchange
3. Risk for Hypothermia
4. Ineffective Health Maintenance
Answer: 1, 2
Explanation: Respiratory compensation for metabolic alkalosis includes depression of the
respiratory rate and reduction of the depth of respirations leading to the retention of carbon
dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit.
With the fluid volume deficit, the patient would experience hyperthermia. Ineffective health
maintenance would not be a priority during the acute phase of the disease but, rather, a teaching
opportunity before discharge depending on the cause of the metabolic alkalosis.
11
5) The nurse is planning care for the patient with Cushing's syndrome who has been admitted for
complications related to the disease process. Which of the following interventions does the nurse
plan for this patient to improve the impaired gas exchange?
1. Administer IV fluids per practitioner order
2. Assess input and output accurately
3. Monitor serum electrolytes
4. Scheduling nursing activities to allow for periods of rest
Answer: 4
Explanation: 4. The patient with Cushing's syndrome is at risk for developing severe metabolic
alkalosis that causes hypoxemia and limits energy reserves. Spacing nursing activities throughout
the day allows the patient ample rest time. The other interventions are aimed at the deficient fluid
volume that may occur with metabolic alkalosis.
Learning Outcome: 5. Create a plan of care for individuals with metabolic alkalosis and their
family members.
6) The nurse is preparing to discharge a patient with congestive heart failure on furosemide
(Lasix). The nurse determines that teaching has been effective if the patient states which of the
following?
1. "I will use only sodium bicarbonate as my antacid."
2. "I will take antacids only for my gastric discomforts."
3. "I will use potassium supplements while I am taking Lasix."
4. "I will restrict my intake of fluids."
Answer: 3
Explanation: 3. The patient on Lasix (furosemide) may lose excess potassium and dispose the
patient toward metabolic alkalosis. The patient is taught to refrain from the use of sodium
antacids when prone to metabolic alkalosis. The patient should consult with the primary care
provider for gastric distress rather than self medication. The patient who is prone to metabolic
alkalosis is likely to have fluid deficits and would not be instructed to restrict fluids.
Learning Outcome: 6. Assess expected outcomes for an individual with metabolic alkalosis.
12
7) A patient with severe metabolic alkalosis has been admitted to the unit and is being cared for
by a nursing student along with the nurse. Which of the following does the nurse tell the student
is a priority treatment for this patient?
1. Monitoring oxygen saturation
2. Administering medication for metabolic alkalosis
3. Teaching the patient the risk factors for metabolic alkalosis
4. Setting goals for the patient with metabolic alkalosis
Answer: 1
Explanation: 1. The priority for this patient is monitoring oxygen saturation. The depressed
respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired
oxygenation of the tissues. Administering medications will be needed as a treatment, but the
priority is to discover the cause. Teaching the patient and setting goals are important aspects of
nursing care but are not the priority.
8) A patient with hyperaldosteronism has been admitted to the unit. The nurse knows the patient
is at risk for impaired gas exchange. Which of the following is the best position for this patient in
order to enhance gas exchange?
1. Right Sims position
2. Left side lying position
3. Fowler's position
4. Prone position
Answer: 3
Explanation: 3. The patient with prolonged vomiting will likely have severe metabolic alkalosis
with reduced oxygenation. The Fowler's position will facilitate alveolar ventilation with
improved oxygenation. Side-lying and prone positions do not facilitate needed lung expansion.
13
Exemplar 1.3: Respiratory Acidosis
1) The nurse has admitted a patient who was brought to the hospital after a morphine overdose.
What acid-base imbalance does the nurse expect to observe in this patient?
Answer: 1
Explanation: 1. Morphine is a narcotic and generally acts to decrease or suppress respirations;
therefore, this patient is probably hyperventilating. The expected acid-base imbalance would be
respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused
by many conditions, none of which are related to this patient's morphine overdose.
direct and indirect causes of respiratory acidosis.
2) The nurse is caring for a patient who has been admitted to the unit with respiratory failure and
respiratory acidosis. What data from the nursing history would the nurse suspect contributed to
the patient's current state of health?
1. Aspiration pneumonia
2. A recent trip to South America
3. Recent recovery from a cold virus
4. Use of ibuprofen for the control of pain
Answer: 1
Explanation: 1. Aspiration of a foreign body and acute pneumonia would put the patient at risk
for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk
factor. Recent recovery from a cold would not likely put the patient at risk. Ibuprofen does not
pose a threat to the respiratory health of the patient.
Learning Outcome: 2. Identify risk factors associated with respiratory acidosis.
14
3) A 10-year-old boy has been admitted to the hospital with respiratory acidosis. The nurse
suspects that which of the following chronic lung diseases most likely caused the child to
develop this condition?
1. Pneumonia
2. Aspiration
3. Cystic fibrosis
4. Hyperthyroidism
Answer: 3
Explanation: 3. Chronic lung disease such as asthma and cystic fibrosis put the child at risk for
respiratory acidosis. Pneumonia and aspiration are both acute lung conditions. Hyperthyroidism
is a disorder that results in metabolic acidosis.
across the lifespan for individuals with respiratory acidosis.
4) A patient has been admitted to the unit with chronic obstructive pulmonary disease. Blood gas
analysis indicates respiratory acidosis. The nurse anticipates which of the following as the
priority nursing diagnosis for this patient?
1. Impaired Gas Exchange
2. Anxiety
3. Impaired Mobility
4. Ineffective Airway Clearance
Answer: 1
Explanation: 1. Impaired gas exchange is the priority nursing diagnosis for the patient with
respiratory acidosis. Interventions are aimed at restoring effective alveolar ventilation and gas
exchange. Anxiety and ineffective airway clearance are both appropriate nursing diagnoses but
not priority for the patient with respiratory acidosis. There is no evidence to support impaired
mobility for this patient.
respiratory acidosis.
15
5) A nurse is working with students on a medical unit. A patient with respiratory acidosis is
being monitored closely, and the nurse is able to describe to the students the pathophysiology
surrounding this patient's condition as well as specific assessment findings. This nurse is
demonstrating which type of knowledge?
1. Aesthetic
2. Empirical
3. Personal
4. Creative
Answer: 2
Explanation: 2. Empirical knowing ranges from factual, observable phenomena to theoretical
analysis. Empirical knowledge is systematic and helps to describe, explain, and predict
phenomena. Aesthetic knowledge is the art of nursing and is expressed by nurses in their
creativity and style in meeting the needs of patients. Personal knowledge is concerned with the
knowing, encountering, and actualizing of the concrete, individual self. Creativity is part of
aesthetic knowledge.
Learning Outcome: 5. Create a plan of care for individuals with respiratory acidosis and their
family members.
6) The nurse is caring for a patient who is being mechanically ventilated. Arterial blood gas
analysis reveals a pH of 7.20 and a PaCO2 of 49mm Hg. Which change in ventilator settings
would the nurse anticipate?
1. Decrease of FiO2 from 30% to 25%
2. Decreased tidal volume of each breath
3. Increased respiratory rate to 30 breaths per minute
4. Increase in humidification of inspired air
Answer: 3
Explanation: 3. This patient is exhibiting respiratory acidosis. This patient needs to "blow off"
more CO2; therefore, the respiratory rate would be increased. No other option given would serve
to decrease CO2 levels.
Learning Outcome: 6. Assess expected outcomes for an individual with respiratory acidosis.
16
7) The nurse is preparing to admit a patient with acute pneumonia that is suffering from with
severe respiratory acidosis. The nurse anticipates that treatment for this patient may be which of
the following? (Select all that apply)
1. Administration of digoxin for heart failure
2. Administer oxygen prn
3. Encourage fluids of up to 3L per day
4. Reposition frequently
5. Place in a prone position.
Answer: 2, 3, 4
Explanation: The patient with acute pneumonia and respiratory acidosis may require oxygen
administration to improve gas exchange, increased fluid intake to thin secretions and frequent
repositioning to preventing the pooling of respiratory sections. There is not enough evidence to
know whether or not the patient is experiencing heart failure as a result of the acute pneumonia.
8) The nurse is providing care to a patient who has recently been extubated after being treated for
aspiration pneumonia that lead to respiratory acidosis. Which of the following actions by the
nurse provides an optimum environment for this patient?
1. Restraining the patient
2. Placing the patient in a side-lying position
3. Allowing family members to remain with patient as much as possible
4. Administering narcotics for pain
Answer: 3
Explanation: 3. The patient with respiratory acidosis often experiences anxiety. This patient
would benefit from having a family member with them to provide reassurance. Restraining the
patient will increase levels of agitation. The patient with respiratory failure would benefit most
by the semi-Fowler's or Fowler's position to increase ventilation. Narcotics will depress the
respirations and increase respiratory acidosis. A non-narcotic pain reliever would be considered
if this patient is experiencing pain.
17
Exemplar 1.4: Respiratory Alkalosis
1) A patient is admitted to the hospital with sudden, severe abdominal pain. Which of the
following values in the arterial blood gas would the nurse expect with respiratory alkalosis?
1. pH is 7.33 and PaCO2 is 36
2. pH is 7.47 and PaCO2 is 25
3. pH is 7.30 and H2CO3- is 30
4. pH is 7.35 and PaO2 is 88
Answer: 2
Explanation: 2. Acute pain usually causes hyperventilation, which causes the CO2 to drop and
the patient to experience respiratory alkalosis. The pH would denote alkalosis and would be
higher than 7.45. H2CO3- would trend downwards as the kidneys begin to compensate for the
alkalosis by excreting H2CO3. The PaO2 is likely to be normal unless the patient has been
hyperventilating for a long time and is beginning to tire.
direct and indirect causes of respiratory alkalosis.
2) The patient is seen in the emergency department with symptoms of a panic attack including
hyperventilation. The nurse suspects that the patient may be at risk for which of the following on
admission?
1. Vomiting and diarrhea
2. Memory loss
3. Hypoventilation
Answer: 4
Explanation: 4. Anxiety disorders increase the risk for the acid-base imbalance respiratory
alkalosis, due to hyperventilation that accompanies anxiety and panic attacks. The patient with
anxiety does not necessarily have vomiting, diarrhea, or memory loss as risk factors. Anxiety and
panic attacks will lead to hyperventilation, not hypoventilation.
Learning Outcome: 2. Identify risk factors associated with respiratory alkalosis.
18
3) The nurse is caring for a Jewish patient who is diagnosed with respiratory alkalosis. The nurse
caring for the patient states to another nurse that "Jewish families are so hard to deal with; all
they do is complain." The nurse is exhibiting which of the following?
1. Prejudice
2. Stereotyping
3. Discrimination
4. Culture shock
Answer: 2
Explanation: 2. The nurse is exhibiting stereotyping by assuming that all members of a culture
or ethnic group are alike. Culture shock is a disorder that occurs in response to transition from
one cultural setting to another. Prejudice is a negative belief or preference that is generalized
about a group and leads to "prejudging." Discrimination occurs when a person acts on prejudice
and denies another person one or more of the fundamental rights.
across the life span for individuals with respiratory alkalosis.
4) The nurse is planning care for a patient who has been admitted to the unit with a salicylate
overdose. When preparing the plan of care, the nurse considers which of the following to be a
priority nursing diagnosis?
1. Impaired Mobility
2. Ineffective Breathing Pattern
3. Risk for Injury
4. Powerlessness
Answer: 2
Explanation: 2. The patient with a salicylate overdose is at risk for hyperventilation, which can
lead to respiratory alkalosis. There is not enough information to know whether the patient's
mobility is impaired. Risk for injury and powerlessness are diagnoses to be considered for this
patient, but the highest priority is respiratory function.
respiratory alkalosis.
19
5) The patient with an anxiety disorder is ready to be discharged from the unit. Which of the
following will the nurse plan to teach this patient and family in preparation for discharge? (Select
all that apply.)
1. Have the patient breathe into a paper bag when feeling anxious.
2. Have the patient eat foods high in acid.
3. Instruct the patient to breathe slowly.
4. Teach the patient the signs of impending panic attack.
5. Refer the patient for counseling.
Answer: 1, 3, 4, 5
Explanation: Teaching the patient to breathe slowly or into a paper bag helps the patient manage
hyperventilation at home. The patient with an anxiety disorder should be referred to counseling
to assist with management of the disorder and should be taught signs of an impending panic
attack. Eating foods high in acid will not counteract the results of hyperventilation.
Learning Outcome: 5. Create a plan of care for individuals with respiratory alkalosis that
includes family members.
6) The nurse has completed discharge teaching for a patient with an anxiety disorder. Which of
the following indicates to the nurse that the patient has understood discharge teaching regarding
respiratory alkalosis?
1. "I will eat more bananas at breakfast."
2. "I will see my counselor on a regular basis."
3. "I will breather faster when I am feeling anxious."
4. "I will not take antacids when I have heartburn."
Answer: 2
Explanation: 2. The patient understands that reducing anxiety can reduce hyperventilation and
respiratory alkalosis. Seeing a counselor can help the patient develop alternative strategies for
dealing with anxiety. Eating bananas is more appropriate for the patient at risk for metabolic
alkalosis who is on diuretics. Breathing faster will increase hyperventilation. Taking too many
antacids is associated with metabolic alkalosis.
Learning Outcome: 6. Assess expected outcomes for an individual with respiratory alkalosis.
20
7) The nurse is preparing to admit a patient who has been diagnosed with respiratory alkalosis
secondary to hyperthermia. Which of the following assessment data by the nurse would suggest
that the patient's condition is deteriorating? (Select all that apply).
1. Decreased rate of respirations
2. Increased level of consciousness
3. Positive Chvostek's sign
4. Positive Moro response
5. Complaints of paresthesia
Answer: 3, 5
Explanation: The patient with respiratory alkalosis should be monitored for signs of tetany as an
indication of a deteriorating condition. A positive Chvostek's sign would indicate that the
patient's calcium levels are dropping and the patient might have tetany. Numbness and tingling
of the hands and mouth, known as paresthesia, also indicate deterioration. The patient with
alkalosis will have a decreased level of consciousness and increased respiratory rate. The Moro
response is a method of assessing the newborn's startle reflex.
8) The nurse is caring for the patient with a history of anxiety that is experiencing chest pain,
palpitations and dyspnea . Which of the following interventions for this patient would be a high
priority for the nurse?
1. Ordering a regular diet for the patient
2. Reassuring the patient that symptoms will resolve
3. Asking respiratory therapy to set up a mechanical ventilator
4. Providing educational material for the patient's medical diagnosis
Answer: 2
Explanation: 2. The patient will require reassurance from the nurse that the symptoms being
experienced are not that of a heart attack and that the symptoms will resolve when a normal
breathing pattern returns to normal. Ordering the diet and instructing the respiratory therapist are
done by the health care provider. Providing teaching for the patient becomes a priority when the
patient is recovering from the illness.
21
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Nunc igitur sedeat sapiens et computet actus,
Quam prius adueniat iudicis illa dies.
Postquam de gaudiis et penis que bonis et

malis debentur tractauit, consulit vlterius quod
unusquisque ad bonos mores se conuertat, et
de hiis que negligenter omisit, absque
desperacione contritus indulgenciam a deo
confidenter imploret.
Cumque repentinum casum breuis hora

Capm. xx.
minatur,632
Dum tenuem flatum suscitat aura leuis,
Care, memento tui, quis sis, cur, vnde vel ad quid,
1110 Vel cuius factus condicionis eras;
Quod caro sit fragilis, fallax facilisque moueri,
Prona sit ad peius, pessima prompta sequi.
Spiritus hunc mundum spernat speretque futura,
Semper in auctoris fixus amore sui:
Quod caro spiritui subdatur eumque sequatur,
Spiritus auctori seruiat ipse suo;
Quod motus carnis moderetur, commemoranda
Est mors et pena mortis habenda malis.
Non poterit melius hominis caro viua domari,
1120 Quam quod mente gerat mortua qualis erit.
Fletibus assiduis, est dum data gracia flendi,
Penituisse iuuat estque salubre satis:
Nec deus ethereus hec crimina vendicat vlli,
Que confessa dolens non residiua facit.
Qui reus est igitur homo, penam temporis huius
Sustineat, donec diluat omne malum;
Vt sic purgatus, cum iudex venerit, illam
Effugiat penam, que sine fine manet:
Nam qui iussa dei non seruat et vltima vite
1130 Spectat, ad infernum cogitur ille trahi.
Scripture fallunt, aut certe noscere debes
Quod redit ad veniam vix animalis homo;
Victus enim vicio vicii fit seruus, et in se
Non habet admissum soluere posse iugum:
Ergo perpes ei debetur pena necesse,
Qui sibi peccandi velle perhenne facit.
Parcere nempe deo proprium tamen et misereri
est,
Vnde, licet sero, te reuocare stude.
Figmentum nostrum nouit, set et ipse medetur
1140 Tandem contritum, qui petit eius opem.
Non te desperes, pius est deus, immo deumque
Qui negat esse pium, denegat esse deum:
Hic quasi fons viuus patet omnibus, et vacuari
Vt fons nescit aquis, hic pietate nequit.
Set quia spem nimiam presumpcio sepe fatigat,
Tu tibi spem pone sicut oportet agi:
Vt sapiens speres, tibi sit tua spes moderanda,
Eius habent sancto frena timore regi.
Non timor excedat, quo desperacio mentem
1150 Polluat, immo deum mentis amore time:
Nec spes presumat, set amet commixta timore,633
Sic timor est virtus spes et vterque salus.
Set meditando tamen tua mens de fine remorsa,
Semper amara timens speret habere bona:
Sanccius vt viuas, memorare nouissima semper,
Ledunt nam iacula visa perante minus.
Respice cotidie, mortis quia tempus adesse
Festinat, que simul prospera cuncta ruet.
Hic loquitur quod sunt modo pauci, qui aut

propter celi affectum aut gehenne metum huius
vite voluptatibus renunciant; set quecumque
caro concupiscit, omni postposita racione,
ardencius perficere conantur.
Capm. xxi. Qui sibi commemorans, puto, singula ponderat
eque,
1160 Senciet a fine gaudia vana fore:
Nunc tamen a viciis est quilibet infatuatus,
Quod de fine suo vix memoratur homo.
Quisque suum corpus colit, et de carnis amore
Gaudet, et est anime causa relicta sue:
Gloria nec celi mentes neque pena gehenne
A mundi labe iam reuocare queunt.
Sic caro, sic demon, sic mundus vbique modernos
Deuiat, vt Cristi vix sciat vnus iter:
Est caro que fragilis, demon versutus, iniqus
1170 Mundus, in hoc hominum tempore regna colunt:
Et sic bruta quasi perit humane racionis
Virtus, dum vicium corporis acta regit.
Est homo nunc animal dicam, set non racionis,
Dum viuit bruti condicione pari.
Nescia scripture brutum natura gubernat,
Iudicis arbitrium nec racionis habet:
Est igitur brutis homo peior, quando voluntas
Preter naturam sola gubernat eum.
Corporis, heu! virtus per singula membra
revoluens
1180 Naturam viciis seruit ad acta foris;
Ac anime racio carnis viciata vigore
De virtute nichil interiore sapit.
Morigeri cicius modo sunt derisio plebis,
Et scola peccati iustificabit opus:
Que solet illa viros veteri de more beare,
Iam noua virtuti frena libido mouet.634
Inter eos mundi quibus est donata potestas,
‘Sic volo, sic iubeo,’ sunt quasi iura modo.
Succumbunt iusti clamantes, ‘Ve! quod in orbe
1190 Impia pars hominum singula regna terit.’
Vis prohibet leges, euertunt crimina mores,
Virtus peccati turbine quassa perit:
Mundus turbatur, rerum confunditur ordo,
Involuitque simul omnia grande chaos.
Squalidus in terra sic stat genitor genitusque,
Quod natura suo vix stat in orbe loco.
Liuor et ambicio, gula, fraus, metuenda libido,
Ira, tumor mentis, scismata, laudis amor,
Ambiciosus honor, amor et sceleratus habendi,
1200 Ipse voluptatis vsus et ecce malus,
Furta, rapina, dolus, metus et periuria, testes
Sunt mundi quod erit ammodo nulla fides.
Hic loquitur de variis vindictis occasione

peccati in hoc seculo iam quasi cotidie635
contingentibus, que absque iustorum virorum
meritis et oracionibus nullatenus sedari
poterunt.
Ecce dies veniunt, predixit quos fore Cristus,

Capm. xxii.
Et patuere diu verba timenda dei.
Precessere fames, pestis, motus quoque terre,
Signaque de celo, stat quoque guerra modo:
Nititur aduersus regnum consurgere regnum,
Gens contra gentem, sic patet omne malum.
Vt pecoris sic est hominis fusus modo sanguis,
1210 Victa iacet pietas, et sinit ista deus:
Est et adhuc vindex extenta manus ferientis
Continuans plagas, nec timet vllus eas.
Longanimis domini sentencia sepe moratur,
Vir bonus inmunis nec malus vllus erit.
Quem deus ille ferit, nullo valet orbe tueri,
Si non contritum culpa relinquat eum.
Mortem peccantis non vult deus, immo misertus
Vult vt vertatur, quo sibi vita datur:
Est pius ipse deus, scripturis sicut habemus,
1220 Pro Sodomis Abrahe dixerat ipse pie:
‘Inter iniquorum tot milia tu populorum
Redde decem iustos, et miserebor eis.
Est michi nam soli proprium miseris misereri,
Multis pro paucis parcere curo libens.’
O deus, ergo tibi quid dicam, quomodo nostri
Luctus continui sunt tibi nuga quasi?
Nonne decem iusti modo sunt, meritis vt eorum
Stellifer ipse dies curet in orbe malos?
Aut deus oblitus est immemor ad miserandum,
1230 Dormit vel fingit, aut sibi facta latent.
Verius vt dicam, deus est accensus, et ignis
Fulminat inde Iacob, iraque lata furit:
Sic et plasma suum plasmator abhorret, et ipsum
Torquet pro factis que videt ipse malis.
O, qui mentali videt ex oculo mala nostra
Omnibus in gradibus continuare dies,
Dicere tunc poterit quod talia nullus ab euo
Impunita diu crimina vidit homo.
Quis status ille modo, quin sit transgressus, et
ordo,
1240 Quem iustum dicam, deficit vnde sciam.
Hoc nisi gratis emat, dubito prope quod generalis
Decasus nostre prosperitatis adest:
Set quia de summis gradibus mala progrediuntur,
Est qui summus eos corrigat ipse deus.
Hic loquitur sub compendio recapitulando

finaliter de singulis mundi gradibus, qui
singillatim a debito deuiantes ordine virtutes
diminuendo extingunt, et ea que viciorum sunt
augmentando multipliciter exercent.
Dudum prelatus solum diuina gerebat,

Capm. xxiii.
Nunc propter mundum nescit habere deum:
Curatus cure dudum seruiuit, et ipse
Nunc vagus exterius circuit omne genus:
Dudum presbiteri casti, nunc luxuriosi;
1250 Ocia que querunt plurima dampna fouent:
Ex studio mores dudum didicere scolares,
Nunc tamen econtra stat viciata scola:
Indiuisus amor monachos sibi strinxit vt ardor,
Nunc petit inuidia claustra tenere sua:
Asperitas dudum fratres in carne domabat,
Regula set mollis ammodo parcet eis:636
Dudum milicia fuit et sibi gracia prompta,
Gracia nunc tarda stat, quia vita mala:
Mercator dudum iustum peciit sibi lucrum,
1260 Nunc quoque fraude sua querit habere lucra:
Simplicitas animi fuerat sociata coloni,
Nunc magis indomitum cor gerit ipse ferum:
Lex dudum iusta nulli parcebat amica,
Quam vigor argenti subdit vbique sibi.
Par status imparibus est actibus attenuatus,
Exceditque suum quisque viator iter.
Sic pietas humilis teritur, que superbia regnat;
Liuor adest agilis, torpet et omnis amor:
Permanet ira ferox, et abit paciencia suplex,
1270 Viuit et accidia, sollicitudo perit:
Ebrietas, non sobrietas, tenet ammodo mensas,
Feruet et in viciis crapula plena cibis:
Casta pudicicia dudum precingere lumbos
Affuit, et modo vult soluere luxus eos:
Nuper larga manus inopi sua munera spersit,
Nunc cupit et bursam claudit auara tenax.
Dic modo quot viciis modo sola superbia
mundum
Ad varii sceleris precipitauit opus:637
Dic quot liuor edax acies sua signa sequentes
1280 Subdidit imperio vique metuque suo:
Dic quot auaricie manibus vel mente rapaci
Intendunt populi iura negando dei;
Quot gula deliciis torpet, quot torpor inanes
Carnis adulterio fedat in orbe suo.
Singula nempe vorat anime caro, sic quod vbique
Subdidit inmundam crimine mundus eam:
Singula fallacis mundi dulcedo subegit,
Nos tamen inmundos mundificare nequit.
Iam in fine libri loquitur magis in speciali de

patria illa in qua natus fuerat, vbi quasi
plangendo conqueritur, qualiter honores et
virtutes veteres a variis ibidem erroribus
superuenientibus, vt dicitur, ad presens
multipliciter eneruantur.
Singula que dominus statuit sibi regna per

Capm. xxiiii.
orbem,
1290 Que magis in Cristi nomine signa gerunt,
Diligo, set propriam super omnia diligo terram,
In qua principium duxit origo meum.
Quicquid agant alie terre, non subruor inde,
Dum tamen ipse foris sisto remotus eis;
Patria set iuuenem que me suscepit alumpnum,
Partibus in cuius semper adhero manens,
Hec si quid patitur, mea viscera compaciuntur,
Nec sine me dampna ferre valebit ea:
Eius in aduersis de pondere sum quasi versus;
1300 Si perstet, persto, si cadat illa, cado.
Que magis ergo grauant presenti tempore, saltem
Vt dicunt alii, scismata plango michi.
Vna meo sensu res est, que pessima cunctis
Iam poterit dici fons et origo mali.
Heu! quia iusticia procul abcessit fugitiua,
Cessit et est alibi pax sociata sibi:
Pax, que iusticie dudum solet oscula ferre,
Nunc fugit a terra, ius perit ecce quia.
Plures iam nocui sumunt sibi regna magistri,
1310 Vis iubet et velle, iura nec vlla videt:
Nunc vbi se vertit magnas, sine iure sequntur
Leges, set populus inde subibit onus:
Corpore sicque meo non tantum torqueor, immo
Sunt michi pro minimo res quibus vtar ego.
Non est de modicis quod adulterium modo ledit;
Que caro deposcit omnia namque licent.
In terris aliis Venus et si predominetur,
Exsoluunt meritis hoc aliunde suis;
Est ibi nam posita lex, que communis ad omnes
1320 Iudicat, et causas terminat absque dolo:
Non status aut sexus, non dona, preces, timor aut
quid
Possunt a minimo tollere iura viro:
Et sic iusticia redimit quodammodo culpam
Carnis, que fragili condicione cadit.
Set nos in patria non solum vincimur ista
Ex carnis stimulo, quo stimulatur homo;
Immo suas metas lex transit nescia iuris,
Sicque per obliquas patria nostra vias
Deuiat in tanto, quod, dicunt, amplius ordo
1330 Non erit in nostris partibus: vnde deus
Visitat has partes vindicta, qualis ab euo
In nullo mundi tempore visa fuit.
Non tamen est terra que gaudet in omnibus vna,
Set magis in nostra fit modo virga fera:
Clamor vbique, vide, non solus conqueror ipse;
Culpas tam patulas est reticere nephas:
Sic fleo cum flente, lex fallit, fallor et ipse;
Stat mea nam grauibus patria plena malis.
Nos, quibus assueuit numquam crudeliter vti
1340 Fatum, iam pressos sternit vbique reos.
Que fuerat tellus omni preciosa metallo,
Iam nequit ex plumbo pondus habere suum;638
Dignior argento, fuluo quoque dignior auro,
Nobile que genuit, vix valet esse quadrans.
Nuper dixerunt quicumque venire solebant,
‘Venimus ad portus, vbera terra, tuos.’
Nunc tamen vt sterilis reputaris et es, quia mores
Nunc neque diuicie sunt aliquando tue.
Quo ferar, vnde petam mestis solacia rebus?
1350 Anchora iam nostram non tenet vlla ratem.
Sic mea, que stabilis fuit, infirmatur iniquis
Patria iudiciis, iura negando viris:
Sic gentis domina, quasi iam viduata, tributa
Reddit peccato, statque remota deo.
Sic que morigera fuerat, nunc est viciosa;
Dudum legifera, nunc sine lege fera:
Sic ea que larga fuerat, nunc tollit egena;
Que fuerat sancta, fit Venus ipsa dea:
Est sale iam spersa, fuerat que fructibus ampla,
1360 Et velut vrtica, que solet esse rosa:
Que fuerat pulcra, quasi monstrum stat reputata;
Fit caput in caudam, sic terit omnis eam.
Scandala feda parit nouiter transgressa nouerca,
Omnis que laudis mater et hospes erat:
Que fuit angelica nuper, nunc angulus extat,
Languet et in tenebris sorde repressa magis.
Patria, quam famam dicunt habuisse sororem,
Est magis infamis omnibus ipsa locis:
Que fuerat digne super omnes celsior orbe,
1370 Nunc deus est alibi, subditur ipsa quasi:
Ordine retrogrado quicquid sibi laudis habebat
Cedit, et instabilis vndique spreta iacet.
Firma mouet, ruit alta, terit modo forcia discors
Error, et innumera spergit vbique mala:
Torpescunt proceres, clerus dissoluitur, vrbes
Discordant, leges sunt sine iure graues:
Murmurat indomitus vulgus, concrescit abvsus
Peccati solitus; sic dolet omnis humus.
Hinc puto quod seuit pes terreus in caput auri,
1380 Et lupus agnorum cornua vana timet.639
In meritis hominum solum deus aspicit orbem,
Et sua de facto tempora causat homo.
O sterilis terra morum, sani viduata

Consilii, lesa nec medicamen habens,
Dic vbi fortuna latitat modo, qua reputabas
Nuper in orbe tuum non habuisse parem.
Si Lachesis sortem tibi contulit esse dolosam,
Iam venit ipsa tui r e d d e r e pacta doli:640
Nunc palletque tuis nigris Aurora venenis,
1390 Cuius lux aliis fulsit in orbe magis;
Nuncque iuuentutis flos que tibi creuit habunde
Aret, et a viciis inveterata peris;
Fedaque nunc volucris, venturi nuncia luctus,
Concinit in fatis bubo propheta tuis.
Scit deus hanc causam specialius esse notandam,
Qua locus iste modo distat honore suo:
Hoc scio, quod cunctis locus in prouerbia crescit,
Et quasi nunc speculum denotat omnis eum.
Talia per terras fatali lege geruntur,
1400 Vt reputant, set ego non ita stare puto:
Non est fortuna, que talia causat habenda,
Nec sors, set merita nostra per acta mala.
Qui tamen hanc stare modo credit et hanc
reuocare
Vult, purget crimen, sic reuocabit eam:
Gracia prompta dei querentibus inuenietur,
Nam sibi conuersis vertitur ipse deus.
Dum pia pro pace cecinit processio terre,
Firmaque iusticia fecerat acta sua,
Dumque fides steterat et amor s i n e l a b e
m a n e b a t,641
Tunc, quia pax viguit, sors bona
1410 c u n c t a t u l i t.
N u n c igitur nostra s i t v i t a d e o renouata,642
Ne sors fortuita plus queat esse mala:
Vota vetusta precum redeant domino dominorum,
Vt redeat dominus cum pietate suis;
Per quem pax et honor et tempora sana redibunt,
Que pro peccato sunt fugitiua modo.
Prospera qui veteris vult temporis esse renata,
Reddat et emendet facta priora nouis.
Est deus ipse piis pius et seuerus iniquis,
1420 Sic valet ob meritum quisquis habere deum.
Nos igitur, domine, tua gracia, que solet olim
Ferre reis veniam, te miserante iuuet:
Anticipet pietas tua nos, ne dicat eorum
Gens, ‘Vbi sit dominus, qui solet esse pius?’
Da, precor, accessum lacrimis, mitissime, nostris,
Nam sine te nullum scis quod habemus opem:
Nunc tua pro lapsis nitatur gracia rebus,
Nostra nec anterior sit tibi culpa memor:
Numquam pigra fuit causis tua gracia nostris:
1430 Est vbi nunc illa, que solet esse salus?
Nos peccatores sumus, et tu plus miserator,
Scit bonitasque tua nos opus esse tuum:
Si plus peccaret vir, plura remittere posses,
Materiam venie sors tibi nostra dedit.
Si quociens homines peccant, tua fulmina mittas,
Exiguo presens tempore mundus erit:
A te pendentem sic cum circumspicis orbem,
Auctor, pacificum fac opus esse tuum.
Nos, deus alme, tui serui, quamuis modo tardi,
1440 Te, non fortunam, credimus esse deum:
Scimus te solum super omnes esse colendum;
Sic nostri solus tu miserere, deus!
Hic loquitur qualiter ea que in hoc presenti

libello quasi sompniando de mundi scripsit
erroribus, non ex se tantum, set ex plebis voce
communi concepit. Consulit tamen finaliter
quod, si quis inde se culpabilem senciat,
priusquam nobis peiora succedant tempora,
suam ex humili corde culpam penitens
emendet.
Capm. xxv. Hos ego compegi versus, quos fuderat in me

Spiritus in sompnis: nox erat illa grauis.
Hec set vt auctor ego non scripsi metra libello,
Que tamen audiui trado legenda tibi:
Non tumor ex capite proprio me scribere fecit
Ista, set vt voces plebis in aure dabant.
Quem sua mens mordet, de voce sit ille remorsus,
1450 Curet vt in melius que tulit egra prius:
Qui tamen inmunem se sentit, ab inde quietus643
Transeat, et meritis sic stet vterque suis.
Quem non culpa grauat mea non sentencia culpat,
L e d i t u r h i n c n u l l u s, sit nisi forte reus:644
N e g r a u e t e r g o t i b i, gibbosus namque
panelli645
Et non sanus equs ferre recusat onus.
Non tamen in specie quemquam de pondere culpe
Accuso, set eo se probet intus homo:
Non ego mordaci distrinxi crimine quemquam,
1460 Nec meus vllius crimina versus habet.
Que sompno cepi, vigilans mea scripta peregi,
Sint bona dicta bonis, et mala linquo malis:
Omnis enim mundum gemit esse dei laceratum
Vindicta nostri pro grauitate mali.
Ergo suam culpam contrito corde, priusquam
Consumpti simus, corrigat ipse malus.
Corrigit hic mundum, qui cor retinet sibi
mundum:
Cor magis vnde regat, hec sibi scripta legat.
Quod scripsi plebis vox est, s e t e t i s t a
v i d e b i s,646
Quo clamat populus, est ibi sepe
1470 d e u s.
Qui bonus est audit bona, set peruersus obaudit,
Ad bona set pronus audiat ista bonus.
Hec ita scripta sciat malus, vt bonus ammodo fiat,
Et bonus hec querat, vt meliora gerat.
Mundus non ledit iustum, bene dummodo credit,
Quando set excedit, mundus ad arma redit:
Mundus erit talis, fuerit viuens homo qualis;
Obstet vitalis quilibet ergo malis.
Culpa quidem lata, qua virtus stat
v i c i a t a ,647
Cum non purgata fuerit set
1480 continuata,
Que meruit fata sunt sibi fine data.
648Explicit libellus qui intitulatur Vox

Clamantis, editus precipue super articulo primi
infortunii, quod infortunato Ricardo secundo in
primordiis regni sui, vt audistis, quasi ex dei
virga649 notabiliter in Anglia contingebat. Et
nunc vlterius, quia ipse non inde remorsus,
immo magis ad modum tiranni induratus,
regnum suum assiduis oppressionibus
incessanter flagellare non desistit, diuine
vindicte flagellum vsque in sue deposicionis
exterminium non inmerito assecutus est. Tres
namque tunc regni nobiles super hoc specialius
moti, scilicet Thomas Dux Glouernie, qui
vulgariter dictus est Cignus, Ricardus Comes
Arundellie, qui dicitur Equs, Thomas Comes de
Warrewyk,650 cuius nomen Vrsus, hii vero
vnanimes cum quibusdam aliis proceribus sibi
adherentibus, vt regie malicie fautores delerent,
ad dei laudem regnique commodum in manu
forti iusto animo viriliter insurrexerunt, prout in
hac consequenti cronica, que tripertita est,
scriptor manifestius declarare intendit.
FOOTNOTES:
590 9 magnanimi CEHDL magnatum S
591 27 Consilium CEHDL
592 43 descessit SHG descescit L decessit CED
593 87 da pinguibus CE
594 125 circumprecordia SG
595 160 Est S Et CEHDL
596 167 grossantur S grassantur HDLT crassantur CEG
597 182 dolum SCGDL suum EHT
598 184 scelus] dolus EH
599 187 rutilans albedo set SCGDL albus paries tamen EHT
600 189f.
Sic foris ex auro tumulus splendescit, et intro

Fetet putredo, vermibus esca caro. EHT
DL have both this couplet and that in the text

601 192 falco SCGDL nisus EHT
602 218 pulchra C
603 237 ingenii H (corr.) Ingenuum L assimulari CE
604 256 ipse SL ille CEHD
605 269 Ordinary paragr. in CDL, no paragr. E
606 291 Ordinary paragr. CEDL
607 350 credet CEHGDL credit S
608 409 seruus CE
609 470 estatis C (ras.)
610 490 Passebatque S
611 535 set] et CEL
612 562 sunt] sint CE
613 599 sitis] satis D
614 611 tradidit] contulit CE
615 684 queris SGL mauis (mavis) CEHD
616 691 regno peccato EHL Regni peccato D
617 707 eum CEHDH₂ enim SGLT
618 721 perinterius GLT
619 767 spernens famam C famam serpens L
620 816 iuuat S iuuant EGDLTH₂
621 Cap. xiii. Heading 1 mortui corporis CH
622 843 redolens dudum CEHD
623 903 nisi] sibi C
624 918 et] est S
625 921 nostre D nostri SCEHGL
626 931 imparat C
627 961 fit S sit CEHGDL
628 997 et om. S
629 Cap. xix. Heading 1 duplici CEGL dupplici SHT duplice D
630 1067 Tethis D
631 1095 si SGL sit CEHD
632 1107 Cumque ST Dumque CEHGDL
633 1151 comixta H
634 1186 mouet] tenet EDLT
635 Cap. xxii. Heading 2 quotidie CED
636 1256 parcit CE
637 1278 opes S
638 1342 suum SG suo CEHDL
639 1380 Et lupus SHDL Pastor et CG (ras.) Lupus et E
640 1388 reddere SEHG soluere CDLT
641 1409 f. commune regebat Perstitit in nobis tunc honor atque
salus EDLTH₂ (gerebat E)
642 1411 Sint igitur nostra bona facta deo renouata EDLTH₂
(reuocata L)
643 1451 inmunen S
644 1454 Text SCEG Sic precor vt nullus DLT
645 1455 Text SCEG Detrahet inde michi DL Se trahit inde michi
T
646 1469 f. Text SCEHG (in ista E) per scripta cauebis Que mala
sunt, ideo te dabis atque deo DLTH₂ (perscripta D)
647 1479-81 DLTH₂ have two lines only, as follows:—
Omnibus ipse tamen peior sum, sed

releuamen
Det michi per flamen conditor orbis.
Amen.1480*
648 Explicit, &c. Explicit libellus qui intitulatur Vox Clamantis

(omitting the rest) EDTH₂ Explicit liber intitulatus Vox
clamantis (omitting the rest) L
649 4 virga dei CHG
650 12 Warwyk CH
CRONICA TRIPERTITA651
Ista tripertita, sequitur que, Opus
mente perita humanum est
Cronica seruetur; nam pars que inquirere
pacem et
prima videtur
persequi eam.
Est opus humanum, pars illa Hoc enim
secunda prophanum fecerunt hii tres
Est opus inferni, pars tercia iure proceres de
superni quibus infra fit
Est opus in Cristo. Vir qui bene mencio, vbi
sentit in isto fides interfuit.
Scire potest mira, quid amor sit, Opus inferni
quid sit et ira: est pacem
Est tamen hoc clamor, ‘Omnia turbare,
iustosque regni
vincit Amor.’ interficere. Hoc
enim Ricardus
c a p i t o s u s65
2 dolosa
circumvencione
facere non
timuit.
Opus in
Cristo est
deponere
superbos de
sede et
exalt a r e
humiles.
Hoc enim
deus fecit;
o d i o sum
R i c a rdum de
Solio suo
proiecit, et
pium Henricum
omni dileccione
gratissimum
cum gloria
sublimari
constituit.
Tolle caput mundi, C ter et sex Hic in prima

lustra fer illi, parte653 cronice
Et decies quinque cum septem comp o s i t o r
post super adde: tempora
Tempus tale nota, qui tunc fuit distinguens,654
causas vnde
Anglia mota. regnum fuit in
Dum stat commotus se diuisum,
Ricardus amore postmodum per
remotus, singula
Principio Regis oritur tractabit.
transgressio legis,
Quo fortuna cadit et humus
retrogreda vadit.
Quomodo surrexit populus, quem
non bene rexit,
Te m p u s a d h u c p l a n g i t s u p e r h o c ,
quod cronica tangit.
Libro testante, stat cronica scripta
per ante;
Est alibi dicta, transit nec ab aure
10 relicta:
Audistis mira, vulgaris que tulit
ira:
Omnibus in villis timuit vir iustus
ab illis.
Rex induratum cor semper habet, Qualiter
neque fatum infortunatus rex
Tale remordebat ipsum, qui iure Ricardus,
virgam dei non
carebat:655 metuens, de
malo in peius
Stultorum vile sibi consilium suam semper
iuuenile maliciam
continuauit.
Legerat, et sectam senium dedit
esse reiectam:
Consilio iuuenum spirauerat ille venenum,
Quo bona predaret procerum, quos mortificaret:
Sic malus ipse malis adhesit, eisque sodalis
20 Efficitur, tota regis pietate remota.
Tunc accusare quosdam presumpsit auare,
Vnde catallorum gazas spoliaret eorum.
Tres sunt antiqui proceres, quos regis iniqui
Ira magis nouit, et eos occidere vouit:
Et sic qui cati pellem cupit excoriati,
Fingebat causas fallaci pectore Nota de
clausas. iudicibus illis,
Caucius vt factum sibi possit qui vt regis
errorem
habere subactum,
precipue contra
Leges conduxit, pro parte suaque illos tres
reduxit: proceres quos
Munere corrupti suadente occidere vellet
timoreque rupti iustificarent,
Legis in errorem regi tribuere literas sub
30 fauorem: eorum sigillis
scriptas
Hii tunc legiste, quicquid rex dixerat erronice
iste, composuerunt.
Federa componunt, que sigilla sub
ordine ponunt.
Tunc rex letatur, super hoc quod fortificatur,
Quo magis ad plenum diffundat ille venenum:656
Tunc aderant tales iuuenes, qui sunt speciales,
Laudantes regem, quia vertit sic sibi legem.
Hoc concernentes alii, que dolos Qualiter tres
metuentes, proceres
Ad defendendum statuunt cito quid predicti de
regis malicia
sit agendum.
secrecius
Tunc rex festinat, et ad hoc sua premuniti in sui
iussa propinat,
Vt tres querantur vbi sunt, et ibi defensionem
40 capiantur. roborati sunt.
Tunc tres, qui iusti fuerant et ad arma robusti,
Factum disponunt et ad hoc sua robora ponunt.
Qui fuerant isti proceres, in nomine Cristi
Expedit vt dicam referens, et eis benedicam.
Si non directe procerum cognomina recte,
Hec tamen obscura referam, latitante figura:
Scribere que tendo si mistica verba legendo
Auribus apportant, verum tamen illa reportant.
Sunt Olor, Vrsus, Equs, stat Nota de
eorum quilibet equs, nominibus trium
Non hii diuisi, set in vnum sunt procerum
predictorum
50 quasi visi:
sub figura.
Penna coronata tribus hiis fuit Comes
associata: Marescallus.
Qui gerit S tandem turmam Strenuissimus
comitatur eandem, Comes
Nobilis ille quidem probus et Derbeie.
iuuenis fuit idem,
Sic quasi de celis interfuit ille fidelis:
Hac sub fortuna presens aquilonica Comes
luna657 Northumbrie,
cuius Signum
Non fuit ad sortem, sequitur set
fuit luna
mente cohortem.658 crescens.
Qui solem gessit tenebrosus Qualiter rex,
lumina nescit, cuius Signum
In Troie metas dum vendicat ipse Sol erat, ciues
dietas. Londonienses
Troia fuit prima, per quem sol tendit pro auxilio ab
eis contra
ad yma;
dictos tres
Pallet in eclipsi populus quia non proceres
fauet ipsi: optinendo
Obsistunt turbe Phebo, ne scandat requisiuit; set illi
60 in vrbe, regis maliciam
Dumque suis alis Cignus fuit perplectentes
imperialis. eidem
Fraus tamen obliquas nubes nullatenus
commouit iniquas, consensierunt.
Extera dum rebus temptauit lumina Qualiter rex
Phebus: Comitem
Cestria surrexit, Aper in qua lumina Oxonie, qui per
aprum
rexit, designatur, vt
Regis vexillum fatue signauerat ipse contra tres
illum. proceres
Set conspiranti deus obstat et antedictos
insidianti, gentes
Quo dolus exosos inuoluit fine bellatrices
secum duceret,
dolosos: in partes
Auxilio Cigni, regis pro parte Cestrie vna
maligni 659 cum regio
Si vis queratur, contraria vis vexillo
70 operatur. destinauit.
Querit Aper latebras, fraudes mortisque
tenebras,660
Quo regnum periat regisque superbia fiat;
Cignus et expresse super hiis que cernit adesse
Prouidet, et curam regni colit ipse futuram:
Ducit Aper gentes, quas concitat arma gerentes,
Liber vt hiis pergat proceresque per omnia
spergat.
Cignus vt hoc sciuit, venientibus Qualiter
obuius iuit, quodam die
Belliger et purgat regnum, quo vita Veneris Comes
Oxonie cum
resurgat:
suis
Cum Venus incepit lucem, sors sequentibus in
bella recepit. conspectu
Stat Tetis a parte, cecidit dum ducis
80 Cestria Marte; 661 Glouernie, qui
Thamisie fluctus capiunt de tunc vulpis
caudam in
sanguine luctus: lancea gessit,
Vicit Olor pennis, sit ei quo vita prope villam
perhennis. Oxonie in
fugam se vertit,

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Postquam de gaudiis et penis que bonis et

Cumque repentinum casum breuis hora

Hic loquitur quod sunt modo pauci, qui aut

Hic loquitur de variis vindictis occasione

Ecce dies veniunt, predixit quos fore Cristus,

Hic loquitur sub compendio recapitulando

Dudum prelatus solum diuina gerebat,

Iam in fine libri loquitur magis in speciali de

Singula que dominus statuit sibi regna per

O sterilis terra morum, sani viduata

Hic loquitur qualiter ea que in hoc presenti

Capm. xxv. Hos ego compegi versus, quos fuderat in me

648Explicit libellus qui intitulatur Vox

Sic foris ex auro tumulus splendescit, et intro

DL have both this couplet and that in the text

Omnibus ipse tamen peior sum, sed

648 Explicit, &c. Explicit libellus qui intitulatur Vox Clamantis

Tolle caput mundi, C ter et sex Hic in prima

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