Evolve Quiz: Gas Exchange

What is a nursing priority to prevent complications in clients with respiratory acidosis? 1 Assessing the nail beds 2 Listening to breath sounds 3 Monitoring breathing status 4 Checking muscle contractions

2

When caring for a client with pneumonia, which nursing intervention is the highest priority? 1 Increase fluid intake. 2 Employ breathing exercises and controlled coughing. 3 Ambulate as much as possible. 4 Maintain a nothing-by-mouth (NPO) stat

2 For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first? 1 Cyanosis 2 Bradycardia 3 Mental confusion 4 Distended neck veins

3 Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco2 of 50 mm Hg, HCO3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? 1 Hypocapnia 2 Hyperkalemia 3 Metabolic alkalosis 4 Respiratory acidosis

3 Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? 1 Side-lying with head elevated 45 degrees 2 Sims with head elevated 90 degrees 3 Semi-Fowler with legs elevated 4 High-Fowler using the bedside table to rest the arms

4

After a gastrectomy, a client has a nasogastric tube to low continuous suction. The client begins to hyperventilate. How does the nurse anticipate that this breathing pattern will alter the client's arterial blood gases? 1 Increase the PO2 level 2 Decrease the pH level 3 Increase the HCO3 level 4 Decrease the Pco2 level

4 Hyperventilation results in the increased elimination of carbon dioxide from the blood. The PO2 level is not affected. The pH level will increase. The carbonic acid level will decrease.

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? 1 7.20 2 7.35 3 7.45 4 7.48

1 The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH.

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client? 1 Spoon-shaped nails 2 Transverse depressions in nails 3 Softening of nail beds and flat nails 4 Red or brown linear streaks in nail bed

3 Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base, and is seen in conditions of oxygen deficiency, such as in heart or pulmonary diseases. Conditions such as iron deficiency anemia and syphilis cause curvature of nails, which is called koilonychia. Transverse depressions in nails indicate a temporary disturbance of nail growth called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, and trichinosis. They are called splinter hemorrhages.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. 1 Radial pulse: 70 2 Temperature: 37 °C 3 Respiratory rate: 14 4 Blood pressure: 110/70 5 Oxygen saturation: 92%

3,4,5 The respiratory rate ranges in older adults from 12 to 20 breaths/min and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95 to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a sign of COPD.

A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? 1 A 65-year-old with pulmonary fibrosis 2 A 24-year-old with uncontrolled type 1 diabetes 3 A 45-year-old who has been vomiting for 3 days 4 A 54-year-old who takes sodium bicarbonate for indigestion

1 The low pH and elevated Pco2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. 1 Headache 2 Irritability 3 Restlessness 4 Hypertension 5 Lightheadedness

1,2,3 Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis [1] [2]. Irritability is a sign of cerebral hypoxia associated with early respiratory acidosis. Restlessness is a sign of cerebral hypoxia associated with early respiratory acidosis. Hypotension, not hypertension, is a key feature of acidosis. Lightheadedness is a symptom of respiratory alkalosis, not acidosis.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially? 1 Encourage the client to exercise during the day. 2 Arrange a referral for a thorough medical evaluation. 3 Explain that this behavior is an attempt to avoid facing daily responsibilities. 4 Identify that the client is describing clinical findings associated with narcolepsy.

2 This behavior is a sign of hypersomnia, and the client needs a medical assessment; it is commonly caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia, and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2 and the acceptable range of arterial PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis, not alkalosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.

Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. 1 Elevated levels of partial arterial oxygen 2 Elevated levels of eosinophils 3 Elevated levels of neutrophils 4 Elevated levels of red blood cells 5 Elevated levels of peripheral capillary oxygen saturation

2,3,4 Elevated levels of eosinophils, neutrophils, and red blood cells are often related to the excessive production of erythropoietin in response to a chronic hypoxic state and indicates possible chronic obstructive pulmonary disease. Elevated levels of partial arterial oxygen and peripheral capillary oxygen saturation are not associated with chronic obstructive pulmonary disease. However, elevated levels of partial arterial oxygen indicate possible excessive oxygen administration. Decreased levels of peripheral capillary oxygen saturation indicate possible impaired ability of hemoglobin to release oxygen to tissues.

The registered nurse is caring for a client admitted to the hospital with chronic obstructive pulmonary disease. Which assessment by the registered nurse before delegating would help to determine the principle of "right person"? 1 "Is the environment conducive for completing the task safely?" 2 "Does the licensed practical nurse (LPN) know about polices of the institution?" 3 "Can the nursing assistive personnel (NAP) evaluate the client's' condition appropriately?" 4 "Does the nursing assistive personnel (NAP) have the knowledge and expertise to perform the task?"

4

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? 1 Cardiac problems 2 Joint inflammation 3 Kidney dysfunction 4 Peripheral neuropathy

1 COPD causes increased pressure in the pulmonary circulation. The right side of the heart hypertrophies (cor pulmonale) [1] [2], causing right ventricular heart failure. The skeletal system is not directly related to the pulmonary system; joint inflammation does not occur because of COPD. Kidney dysfunction is not as closely related to the pulmonary system as is the cardiac system; kidney problems usually do not occur because of COPD. Peripheral nerves are not as closely related to the pulmonary system as to the cardiac system; peripheral neuropathy does not occur because of COPD.

A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing plan of care for this child? 1 Rest 2 Exercise 3 Nutrition 4 Elimination

1 Rest reduces the need for oxygen and minimizes metabolic needs during the acute, febrile stage of the disease. The child requiring hospitalization for pneumonia is usually confined to bed and needs to reduce activity to conserve oxygen. Nutrition is not a priority; the child is expected to be anorectic during the febrile phase. Elimination is usually not a problem, except as a result of immobility.

A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client? 1 Limiting hydration 2 Improving ventilation 3 Decreasing exogenous oxygen 4 Correcting the bicarbonate deficit

2 Improving ventilation provides comfort, maintains existing lung function, and prevents further lung damage. Maintaining, not limiting, hydration thins secretions so that ventilation is improved. Oxygen administration should be maintained at no higher than 2 L per minute; this provides oxygen while preventing the development of CO2 narcosis. Bicarbonate usually is not given because the client probably is in compensated respiratory acidosis.

Which intervention should the nurse take immediately when an apnea monitor sounds an alarm 10 seconds after cessation of respirations? 1 Assess for changes in skin color 2 Use tactile stimuli on the chest or extremities 3 Check the monitor for signs of a malfunction 4 Resuscitate with a facemask and an Ambu bag

2 The nurse applies tactile stimulation after confirming that respirations are absent; this action may be sufficient to reestablish respirations in the high-risk neonate with frequent episodes of apnea. Assessment will not interrupt the period of apnea; respirations must be reestablished immediately. The monitor should be assessed for proper function before use. Resuscitation with a bag-valve mask is too invasive and aggressive for an initial intervention; gentle stimulation should be attempted first.

The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction? 1 Recording the volume of the air inspired 2 Performing 10 breaths per session every hour 3 Inhaling air fully before inserting the mouthpiece 4 Taking a long, slow, deep breath keeping the mouthpiece in place

3 Incentive spirometry is used to improve inspiratory muscle action and to prevent or reverse atelectasis in a client with pneumonia. The client is instructed to exhale fully and then insert the mouthpiece. Inhaling the air before inserting the mouthpiece may cause harm to the client and therefore needs correction. After the process is completed, the volume of air inspired is recorded. A client with pneumonia is instructed to perform 10 breaths per session every hour while awake. Taking a long, slow, deep breath keeping the mouthpiece in place helps to improve inspiratory muscle action.

The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. What should the nurse document in the client's assessment record based on this finding? 1 Rhonchi 2 Wheezes 3 Fine crackles 4 Coarse crackles

4 A series of long, discontinuous low-pitched sounds similar to blowing through straw under water indicates coarse crackles. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur as a result of an obstruction of the large airways. Wheezes are continuous high-pitched squeaking or musical sounds that indicate airway obstruction. Fine crackles are short, discontinuous, high-pitched sounds like hair being rolled between fingers just behind the ear, heard just before the end of inspiration.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? 1 Increased appetite 2 Clubbing of the nail beds 3 Hypertension 4 Weight gain

4 The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? 1 Administer continuous oxygen 2 Increase fluid intake to at least 2 L a day 3 Place the client in a high-Fowler position 4 Instruct the client to gargle deep in the throat using warmed normal saline

Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary. Placing the client in a high-Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx.

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C & S) are prescribed. Place these interventions in the order in which they should be implemented. 1. Obtain blood specimens for C & S. 2. Provide oxygen via nasal cannula. 3. Promote bed rest with raised head of bed. 4. Administer prescribed antibiotic.

The client's respiratory status is the priority. Promoting bed rest with raised head of bed reduces oxygen demand and administering oxygen via nasal cannula increases the supply of oxygen to the alveolar capillaries. Obtaining specimens for culture and sensitivity must be performed before administering antibiotics, which prevents false microbiologic interpretation caused by the effect of the antibiotic.

A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco2 is 35 mm Hg, and HCO3- is 17 mEq/L (17 mmol/L). What complication does the nurse conclude has developed? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 The blood pH indicates acidosis; the bicarbonate (HCO3-) level is further from the expected range than is the partial pressure of carbon dioxide (Pco2), indicating a metabolic origin (losses from diarrhea), not a respiratory origin. The blood pH indicates acidosis, not alkalosis

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1 Fatigue related to weight loss secondary to COPD 2 Imbalanced nutrition: less than body requirements, related to fatigue 3 Imbalanced nutrition: less than body requirements, related to COPD 4 Ineffective breathing pattern, related to alveolar hypoventilation

2 The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have? 1 Laryngeal trauma 2 Vocal cord paralysis 3 Obstructive sleep apnea 4 Subcutaneous emphysema

3 Obstructive sleep apnea (OSA) is a condition in which the client may feel tired upon waking in the morning and may feel sleepy during the daytime. These clients may also snore heavily while sleeping. Smoking and enlarged tonsils increase the risk of sleep apnea.

A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue? 1 Provide small, frequent meals 2 Encourage pursed-lip breathing 3 Schedule nursing activities to allow for rest 4 Encourage bed rest until energy level improves

3 Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.

The nurse provides instructions about how to use a metered-dose inhaler (MDI) to a client with chronic obstructive pulmonary disease. The nurse concludes that additional teaching is needed when the client demonstrates which technique? 1 Places the tip of the inhaler just past the lips 2 Holds the inspired breath for at least 3 seconds 3 Exhales slowly through the mouth with lips pursed slightly 4 Inhales rapidly with the lips sealed around the nebulizer opening

4 The client should inhale slowly rather than rapidly when using a metered-dose inhaler (MDI) in order to optimize delivery of the nebulized drug into the lungs. If the client has a dry powder inhaler (DPI), then rapid inhaling would be an important action because the powder is not nebulized. The MDI should be gently held in the mouth just past the lips to deliver the medication into the airway. Holding the inspired breath for at least 3 seconds promotes contact of the medication with the bronchial mucosa. Exhaling slowly through the mouth with lips pursed slightly prolongs and improves delivery of the medication to the respiratory mucosa.

The son of a 65-year-old client said, "My father is suffering from chronic lung disease. He wakes suddenly from sleep and is unable to breathe." What condition does the nurse suspect in the client? 1 Orthopnea 2 Hemoptysis 3 Histoplasmosis 4 Paroxysmal nocturnal dyspnea

4 The symptoms of paroxysmal nocturnal dyspnea (PND), which includes waking up suddenly with an inability to breathe, usually develop after the client has been lying down for several hours. PND often occurs in clients with chronic lung disease. Orthopnea is a condition that causes shortness of breath when lying down; this condition is relieved by sitting up. Hemoptysis is characterized by the presence of blood in the sputum; this condition is generally seen in clients with chronic bronchitis or lung cancer. Histoplasmosis is a fungal respiratory infection caused by the inhalation of contaminated dust.