Respiratory Acidosis
The nurse cares for a client with acute respiratory failure who presents with increased agitation, shortness of breath, and irritability. Which nursing diagnosis is most appropriate for this client? A. Fluid Volume: Deficit, Risk for B. Injury, Risk for C. Cardiac Output, Decreased D. Activity Intolerance, Risk for
injury, risk for Rationale: This client is at risk for injury because of the current state, and the nurse should remain at the client's bedside to avoid injury, such as falls. The client may have decreased cardiac output; however, there is not enough information in the question to support this. The client will have activity intolerance and may be at risk of fluid volume deficit, but these are not the priority. (NANDA-I ©2014)
If excessive administration of narcotics has caused respiratory acidosis, which drug will be given to reverse the effects? A. Nonsteroidal anti-inflammatory drugs (NSAIDs) B. Bronchodilators C. Naloxone D. Antibiotics
naloxone Rationale: Naloxone reverses the effects of narcotics. Antibiotics are prescribed to treat infections. Bronchodilators are used to open the airway. NSAIDs are anti-inflammatory analgesics.
A client is diagnosed with metabolic alkalosis. Which action by the nurse will assist in restoring this imbalance? A. Administering potassium chloride B. Administering sodium bicarbonate C. Administering IV insulin D. Administering a bronchodilator
A. Administering potassium chloride Rationale: In metabolic alkalosis, the administration of potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions. Sodium bicarbonate is used to treat metabolic acidosis, not metabolic alkalosis. IV insulin is used to treat diabetic ketoacidosis, a type of metabolic acidosis, not metabolic alkalosis. Bronchodilators are used to treat respiratory acidosis, not metabolic alkalosis.
The nurse is caring for a client with COPD who is anxious and short of breath. A supportive family member is at the bedside, but the client still appears anxious. How should the nurse respond? A. Ask another nurse to sit with the client. B. Allow the family member to stay with the client. C. Politely ask the family member to leave. D. Call the healthcare provider for advice.
B. Allow the family member to stay with the client. Rationale: A client with COPD who is anxious and short of breath is at high risk for acute respiratory acidosis due to further impairment of alveolar ventilation and increased hypercapnia. A client who is experiencing acute anxiety should have a family member at the bedside, as long as the family member is supportive and does not impede the care of the client. There is no reason for the nurse to ask the family member to leave. Calling the healthcare provider or asking another nurse is inappropriate and unnecessary.
The nurse is caring for a client with emphysema who requires supplemental oxygen. Which technique would the nurse instruct the client to perform to promote the removal of excess carbon dioxide from the blood? A. Deep breathing and coughing B. Pursed-lip breathing C. Rapid, shallow breathing D. Huff coughing
B. Pursed-lip breathing Rationale: Pursed-lip breathing promotes the removal of carbon dioxide from the blood because it allows the airways to remain open throughout the entire exhalation, removing more carbon dioxide than if the technique was not used. Huff coughing and deep breathing and coughing are techniques used to remove retained secretions from the airway. Rapid, shallow breathing is not recommended and is not a safe intervention.
The nurse is caring for a client with respiratory acidosis with a nursing diagnosis of Injury, Risk for. What factor increases the client's risk for injury? A. Photophobia B. Muscle tetany C. Blurred vision D. Muscle atrophy
blurred vision Rationale: A client with respiratory acidosis may experience blurred vision, increasing the risk for injury due to falls. Photophobia occurs in meningitis, not respiratory acidosis. Muscle tetany occurs in respiratory alkalosis, not acidosis. Muscle weakness, not atrophy, is associated with respiratory acidosis. (NANDA-I © 2014)
Which intervention would be an effective pharmacologic treatment for improving ventilation for the client experiencing severe respiratory acidosis? A. Bronchodilators B. Intubation C. Hydration D. Percussion and drainage
broncodilators Rationale: Bronchodilators are medications that are used to treat severe respiratory acidosis. Intubation, percussion and drainage, and hydration are nonpharmacologic interventions appropriate for severe respiratory acidosis.
Excess levels of which class of medication can be a risk factor in the development of respiratory acidosis? A. Narcotics B. Antibiotics C. Bronchodilators D. Salicylates
narcotics Rationale: An overdose of narcotics will depress respiratory drive and may cause respiratory acidosis. Excess levels of bronchodilators or antibiotics will not cause respiratory acidosis. An overdose of salicylates can cause respiratory alkalosis, not acidosis.
When planning care for the client with respiratory acidosis, which is the most appropriate intervention for the nurse to implement to promote the removal of excess carbon dioxide? A. Use of bronchodilators B. Pursed-lip breathing C. Huff coughing D. Use of incentive spirometry
pursed-lip breathing Rationale: Pursed-lip breathing is the most appropriate intervention because it promotes the removal of excess carbon dioxide. It maintains open airways throughout exhalation, promoting the removal of carbon dioxide. Huff coughing and the use of incentive spirometry are techniques used to remove excess secretions, not carbon dioxide. Bronchodilators are used to dilate the smooth muscles of the airway during airway constriction.
Which is the priority nursing diagnosis for a client with respiratory acidosis? A. Airway Clearance, Ineffective B. Infection, Risk for C. Nutrition, Imbalanced: Less than Body Requirements D. Bleeding, Risk for
A. Airway Clearance, Ineffective Rationale: The priority nursing diagnosis for the client with respiratory acidosis is Airway Clearance, Ineffective.. Infection, Risk for; Nutrition, Imbalanced: Less than Body Requirements; and Bleeding, Risk for are not appropriate nursing diagnoses for this client. (NANDA-I ©2014)
The nurse is caring for a client with a history of respiratory acidosis secondary to chronic lung disease. Which instruction would the nurse provide regarding prevention of a recurrence of respiratory acidosis? (Select all that apply.) A. Avoid crowds. B. Get the flu vaccine. C. Practice hand hygiene. D. Use good cough etiquette. E. Breathe into a paper bag when out of breath.
A. Avoid crowds. B. Get the flu vaccine. C. Practice hand hygiene. D. Use good cough etiquette. Rationale: Practicing good hand hygiene, using good cough etiquette, avoiding crowds, and getting the flu vaccine will all prevent infections and help prevent a recurrence of respiratory acidosis in the client with a chronic lung disease. Breathing into a paper bag does not prevent respiratory acidosis for a client with chronic lung disease.
A client with severe respiratory distress has a blood pH of less than 7.35. Which clinical manifestation will the nurse anticipate upon assessment? (Select all that apply). A. Headache B. Irritability C. Hyperventilation D. Dizziness E. Tetany
A. Headache B. Irritability Rationale: The client presented in the question has respiratory acidosis (blood pH less than 7.35 in acute respiratory distress). Headache and irritability may be present in clients with respiratory acidosis. Hyperventilation, dizziness, and tetany are symptoms of respiratory alkalosis, not acidosis.
The nurse is reviewing the medication orders for a client with acute respiratory acidosis caused by a narcotic overdose. Which medication would the nurse anticipate being prescribed for the client? (Select all that apply.) A. Naloxone B. Antibiotics C. Anesthetics D. Bronchodilators E. Sodium bicarbonate
A. Naloxone D. Bronchodilators E. Sodium bicarbonate Rationale: Sodium bicarbonate is administered to remove excess acids and increase the pH. Naloxone is given to counter the narcotic overdose. Bronchodilators may also be prescribed to open the airways and improve ventilation. Antibiotics would not be given because this client's acidosis is not caused by a respiratory infection. Anesthetics would not be given because they would further depress respiration.
A client with chronic lung disease diagnosed with acute respiratory acidosis is being discharged home. In order to provide individualized care, which topic should be the priority focus of the nurse's teaching to the client and the client's family? A. Prevention of further compromise B. Supplemental oxygen therapy guidelines C. Instruction on home-regimen instruction D. Follow-up care within the community
A. Prevention of further compromise Rationale: Prevention of further compromise should be the nurse's priority teaching. The other answer choices may be correct; however, these are not the priority for teaching.
The nurse is providing discharge teaching to a 36-year-old client who was treated for respiratory acidosis caused by a narcotic overdose. Which would the nurse likely provide to the client to prevent a recurrence of respiratory acidosis? (Select all that apply.) A. Referral to counseling B. Referral to Narcotics Anonymous C. Resources for family support D. Recommendation for pneumococcal pneumonia vaccine E. Recommendation for influenza vaccine
A. Referral to counseling B. Referral to Narcotics Anonymous C. Resources for family support Rationale: Because the client's respiratory acidosis was caused by a narcotic overdose, the nurse's priority is to provide mental health support for the client and his family. This includes referral to Narcotics Anonymous and counseling, and providing the client's family with support resources. Recommending vaccines against influenza and pneumococcal pneumonia is more appropriate for clients with chronic lung disease.
The nurse asks a new gradate to explain respiratory acidosis. Which statement by the new graduate demonstrates understanding of the pathophysiology of respiratory acidosis? A. "It is caused by an excess of carbonic acid." B. "It is caused by a deficiency of bicarbonate." C. "It is caused by an excess of bicarbonate." D. "It is caused by a deficiency of carbonic acid."
A. "It is caused by an excess of carbonic acid." Rationale: Respiratory acidosis is caused by an excess of carbon dioxide (carbonic acid). A deficiency of carbonic acid would cause respiratory alkalosis. An excess of bicarbonate would cause metabolic alkalosis, whereas a deficiency of bicarbonate would cause metabolic acidosis.
A nurse cares for a client with acute respiratory acidosis. Which intervention will the nurse implement in order to promote the client's gas exchange? A. Encourage huff breathing. B. Place the client in semi-Fowler position. C. Place the client in postural drainage positions. D. Encourage fluid intake.
B. Place the client in semi-Fowler position. Rationale: Placing the client in semi-Fowler position promotes lung expansion and gas exchange. Huff breathing, increased fluid intake, and postural drainage are all interventions to promote effective airway clearance, not to promote gas exchange
Which is a common cause of acute respiratory acidosis? (Select all that apply.) A. Anxiety B. Pneumonia C. Opiate overdose D. Pulmonary edema E. Foreign body aspiration
B. Pneumonia C. Opiate overdose D. Pulmonary edema E. Foreign body aspiration Rationale: Respiratory acidosis is always caused by hypoventilation. The common acute causes of respiratory acidosis that lead to hypoventilation include pulmonary edema, pneumonia, acute asthma, opiate overdose, foreign body aspiration, and chest trauma. Anxiety is a common cause of respiratory alkalosis, not respiratory acidosis.
Which will the nurse include in the client interview portion of the nursing assessment for a client with respiratory acidosis? A. Mental status B. Lung sounds C. Duration of symptoms D. Vital signs
C. Duration of symptoms Rationale: The client interview portion of the nursing assessment for a client with respiratory acidosis will include an assessment of the duration of symptoms. Mental status, vital signs, and lung sounds are assessed during the physical examination, not the interview portion of the nursing assessment.
Why are children with asthma at risk for developing respiratory acidosis? A. Asthma causes decreased oxygenation. B. Asthma causes hyperventilation. C. Asthma causes chronic cough. D. Asthma causes airway constriction.
D. Asthma causes airway constriction. Rationale: Children with asthma are at risk for developing respiratory acidosis because asthma constricts the airways, leading to air trapping and retained carbon dioxide. Hyperventilation would lead to respiratory alkalosis, not acidosis. Asthma may cause chronic cough and decreased oxygenation; however, these are not primary factors related to respiratory acidosis.
