Test 2 questions
metabolic acidosis or alkalosis: High pH and high bicarbonate
metabolic alkalosis
metabolic acidosis or alkalosis: Kidneys excrete bicarbonate
metabolic alkalosis
Which acid-base imbalance is caused by this condition? Inadequate mechanical ventilation
respiratory acidosis
Which acid-base imbalance is caused by this condition? airway obstruction due to neck edema, or localized lymph node enlargement, foreign bodies, or mucus
respiratory acidosis
Which acid-base imbalance is caused by this condition? alveolar-capillary blockage secondary to pulmonary embolus, thrombus, acute respiratory distress syndrome, chest trauma, drowning, or pulmonary edema
respiratory acidosis
Which acid-base imbalance is caused by this condition? brain tumor
respiratory acidosis
Which acid-base imbalance is caused by this condition? cerebral aneurysm
respiratory acidosis
Which acid-base imbalance is caused by this condition? chest trauma
respiratory acidosis
Which acid-base imbalance is caused by this condition? hypoventilation/respiratory depression (could be due to opioids, poisons, anesthetics)
respiratory acidosis
Which acid-base imbalance is caused by this condition? inadequate chest expansion due to muscle weakness, pneumothorax/hemothorax, flail chest, obesity, sleep apnea, tumors, deformities
respiratory acidosis
Which acid-base imbalance is caused by this condition? neurologic diseases such as myasthenia gravis, Guillain-Barre
respiratory acidosis
Which acid-base imbalance is caused by this condition? overhydration
respiratory acidosis
Which acid-base imbalance is caused by this condition? stroke
respiratory acidosis
pH: 7.12 PaO2: 56 mm Hg PaCO2: 65 mm Hg HCO3: 22 mEq/L
respiratory acidosis
pH: 7.30 PaO2: 86 mm Hg PaCO2: 55 mm Hg HCO3: 22 mEq/L
respiratory acidosis
Which acid-base imbalance is caused by this condition? Hypoxemia from asphyxiation, high altitudes, shock, early-stage asthma or pneumonia
respiratory alkalosis
Which acid-base imbalance is caused by this condition? excessive mechanical ventilation
respiratory alkalosis
Which acid-base imbalance is caused by this condition? intracerebral trauma
respiratory alkalosis
Which acid-base imbalance is caused by this condition? salicylate toxicity
respiratory alkalosis
pH: 7.48 PaO2: 68 mm Hg PaCO2: 30 mm Hg HCO3: 24 mEq/L
respiratory alkalosis
pH: 7.5 PaO2: 98 mm Hg PaCO2: 26 mm Hg HCO3: 22 mEq/L
respiratory alkalosis
Magnesium level
1.8-2.6
Sodium level
136-145
HCO3 range
22-28 mEq/L
PaCO2 range
35-45 mmHg
Potassium level
3.5-4.5
pH range
7.35-7.45
PaO2 range
80-100 mmHg
calcium level
9-10.5
Chloride level
98-106
A 12 year old client is being treated for ARDS. Which assessment finding would be indicative of the nursing diagnosis of Impaired Gas Exchange? A. Oxygen saturation of 62% B. Heart rate of 100bpm C. Respiratory rate of 60min D. Bicarbonate level of 38mEq.L
A
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by a unit nurse indicates the teaching has been effective? A. "Metabolic acidosis can occur due to diabetic ketoacidosis." B. "Metabolic acidosis can occur in a client who has myasthenia gravis." C. "Metabolic acidosis can occur in a client who has asthma." D. "Metabolic acidosis can occur due to cancer."
A
A child with asthma has a PaCO2 of 48mmHg, a pH of 7.31, and a HCO3 of 24. The nurse interprets these findings as indicative of which condition? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A
A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia that is unresponsive to oxygen therapy. In explaining the client's condition to the family, the nurse would incorporate which concept? A. Due to complex damage of the alveoli, gas exchange cannot occur B. The individual has difficulty expelling air trapped in the alveoli C. There is excess surfactant production by the alveoli D. Thick secretions block the airways
A
A client with hyperaldosteronism is admitted to the unit and is at risk for impaired gas exchange. In which position should this client be placed to enhance gas exchange? A. Fowler B. Sims C. Prone D. Lateral
A
A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? a)A 65-year-old with pulmonary fibrosis b)A 24-year-old with uncontrolled type 1 diabetes c)A 45-year-old who has been vomiting for 3 days d)A 54-year-old who takes sodium bicarbonate for indigestion
A
A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi
A
A nurse is assessing a client who is being discharged. The nurse notes that client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following? A. Normal breathing B. Kussmaul breathing C. Cheyne-Stokes breathing D. Apnea
A
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? a)Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate b)Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention c)Inability of the renal tubules to reabsorb water to dilute the acid contents of blood d)Impaired glomerular filtration, causing retention of sodium and metabolic waste products
A
A nurse is caring for a client who has a chest tube in place. Which of the following strategies should the nurse use to help promote comfort for the client? A. have the client splint the affected side during coughing B. Perform passive range-of-motion exercises C. Place the client in a supine position with minimal elevation D. Encourage ambulation
A
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? A. Monitor the client for subcutaneous emphysema. B. Expect continuous bubbling in the water seal chamber C. keep the drainage system above the level of the client's chest D. Clamp the chest tube tubing when the client ambulates
A
A nurse is caring for a client who has a cuffed endotracheal (ET) tube in place. Which of the following actions should the nurse plan to take? A. Repositioning the ET tube in the client's mouth every 12hr B. Providing oral care every 24 hr C. Applying the securing tape over the client's ears D. Maintaining a cuff pressure of 35mmHg
A
A nurse is caring for a client who has been receiving oxygen therapy via nasal cannula for 4hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective? A. Respiratory rate 14/min B. SaO2 90% C. Cardiac output 5.6L/min D. PaCO2 68mmHg
A
A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia
A
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client? A. Increase the carbon dioxide level B. Increase the respiratory rate C. Increase the bicarbonate level D. Increase the pH level
A
A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings
A
A nurse is caring for a client who requires 1L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use? A. Nasal cannula B. Nonrebreather mask C. Partial rebreather mask D. Simple face mask
A
A nurse is caring for a client who was in a motor vehicle accident. The client reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following ABG findings should the nurse expect? A. pH 7.06, PaO2 86mmHg, PaCO2 52mmHg, HCO3 24mEq/L B. pH 7.42, PaCO2 100mmHg, PaCO2 38mmHg, HCO3 23mEq/L C. pH 6.98, PaO2 100mmHg, PaCO2 30mmHg, HCO3 18mEq/L D. pH 7.58, PaO2 96mmHg, PaCO2 38mmHg, HCO3 39 mEq/L
A
A nurse is planning education for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following instructions should the nurse plan to provide when the client is ready to ambulate? A. Keep the collection device upright at all times B. Disconnect the system when showering C. Keep the collection device at chest level at all times D. Allow the tubing to hang in a dependent loop when ambulating
A
A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include? A. "Place the oxygen tank in a clutter-free environment." B, "Keep the oxygen tank at least 6 feet away from a heat source." C. "Ensure you are close to electricity to use your oxygen tank." D. "Turn the valve on the oxygen tank until an alarm sounds."
A
A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32mmHg, and HCO3 24mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis
A
A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A. Acidosis B. Infection C. Hypertension D. Cardiac tamponade
A
A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from thyroid storm
A
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, Pco 2 is 35 mm Hg, and HCO 3 - is 17 mEq/L (17 mmol/L). What complication does the nurse conclude has developed? a)Metabolic acidosis b)Metabolic alkalosis c)Respiratory acidosis d)Respiratory alkalosis
A
Administering oxygen therapy with a nonrebreather mask has which of the following advantages? A. offers the highest oxygen concentration of the low-flow systems B. Provides oxygen concentrations of 40-60% C. Incorporates a design that requires minimal monitoring of the client D. Is designed for safety once the mask's valves and flaps are sealed
A
An intervention that ca be implemented independently by the nurse caring for a client with an acid-base imbalance is A. Monitoring I&O B. Drawing blood for ABGs C. Giving sodium bicarbonate infusions D. Administering oxygen via nasal cannula
A
During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? a)Metabolic acidosis b)Metabolic alkalosis c)Respiratory acidosis d)Respiratory alkalosis
A
Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings? A. Elevated BP B. Decreased respiratory rate C. Cyanosis D. Peripheral edema
A
Which information is essential for the nurse to gather prior to administration of potassium intravenously to the elderly client? A.The client's urine output B.The client's electrocardiogram results C.If the client is experiencing dizziness or not D.If the client is experiencing muscle cramps or not
A
Which patient is of greatest risk of developing ARDS? A. 24 year old male admitted with blunt chest trauma and aspiration B. 56 year old male with a hx of ETOH abuse and chronic pancreatitis C. 72 year old male post heart valve surgery receiving 1 unit of packed RBCs D. 82 year old female on antibiotics for pneumonia
A
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (SATA) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing
A B C E
A nurse is providing teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? SATA A. Post a "No Smoking" sign inside the home B. Attach oxygen containers to a fixed object C. Store spare oxygen containers in a closet D. Notify the fire department that oxygen is used in the home E. Ensure oxygen tubing is no longer than 60ft in length
A B D
On reviewing the data of a client with thyroid disorder, the primary healthcare provider prescribed atenolol. Which assessment findings would indicate the need for atenolol therapy? Select all that apply. a)Tachycardia b)Atrial fibrillation c)Distant heart sounds d)Systolic hypertension e)Decreased cardiac output
A B D
Which nursing interventions may promote safe drug administration in a child diagnosed with heart failure who is receiving digoxin? Select all that apply. a)Checking for compliance with the client's drug regimen b) Monitoring the client's serum potassium and magnesium levels regularly c) Administering digoxin only through the intramuscular route d)Calculating the correct dosage form, prescribed amounts, and the prescriber's order e)Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly
A B D E
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SATA A. Encourage the client to cough and deep breathe B. Check for continuous bubbling in the suction chamber C. Strip the drainage tubing every 4 hr D. Clamp the tube once a day E. Obtain a chest x-ray
A B E
A nurse is reviewing ABG values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect? SATA A. HCO3 19mEq/L B. pH 7.29 C. PaCO2 49mmHg D. pH 7.49 E. PaCO2 35mmHg
A B E
A nursing supervisor sends an unlicensed healthcare worker to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the health care worker? Select all that apply. a)Taking routine vital signs b)Applying a sterile dressing c)Answering clients' call lights d)Administering saline infusions e)Assessing client's response to ambulation
A C
The nurse is caring for the client experiencing hypovolemic shock and metabolic acidosis. Which therapies would the nurse question if planned for this client? SATA A. Monitor weight on admission and sicharge B. Monitor EKG for conduction problems C. Limit the intake of fluids D. Administer sodium bicarbonate E. Keep the bed in the locked and low position
A C
A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? SATA A. Tracheal deviation to the left B. Temperature of 102F C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea
A C D
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? a)Respiratory alkalosis b)Respiratory acidosis c)Metabolic alkalosis d)Metabolic acidosis
B
A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must A. clean the mask with soapy water once every other day B. reposition the elastic band frequently C. apply petroleum jelly around and inside the nares D. make sure there is adequate condensation in the tubing
B
A nurse addresses the needs of a client who is hyperventilating to prevent what complication? a)Cardiac arrest b)Carbonic acid deficit c)Reduction in serum pH d)Excess oxygen saturation
B
A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding? A. Jugular vein distention B. Clubbing of the fingers C. Heart murmur D. Paradoxical breathing
B
A nurse is assessing a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity? A. Hypertension B. Ringing in the ears C. Fever D. Dilated pupils
B
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x-ray B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess respiratory status
B
A nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed-chest drainage system? A. Instruct the client to inhale deeply B. Submerge the end of the chest tube in 1 inch of sterile water C. Gently milk the chest tube in a proximal-to-distal direction D. Tape sterile gauze around the open end of the chest tube
B
A nurse is caring for a client who has a chest tube in place that is attached to water-seal drainage system. Which of the following findings should the nurse recognize as indication of subcutaneous emphysema? A. Diminished lung sounds on the affected side B. A dry, crackling sound at the insertion site when palpated C. Absence of drainage in the collection chamber D. Hyperresonance when percussing the affected lung
B
A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilator's circuitry C. Decreased lung compliance D. The client coughing or attempting to talk
B
A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client? A. Distilled water for humidification B. A tracheostomy collar C. A nasal cannula D. An aerosol mask
B
A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first? A. Initiate continuous cardiac monitoring B. Elevate the head of the client's bed C. Instruct the client to deep breathe and cough D. Initiate continuous SpO2 monitoring
B
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask
B
A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange? A. Assessment B. Diagnosis C. Planning D. Evaluation
B
A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."
B
A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia? A. DKA B. Smoke inhalation C. Administration of a stimulant medication D. Right-sided heart failure
B
A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis
B
A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations? A. Trachea B. Alveoli C. Diaphragm D. Bronchial Tubes
B
A nurse is planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first? A. A client who requires teaching about a new cholesterol-lowering medication B. A client who reports dyspnea when walking to the bathroom C. A client who has a new diagnosis of aortic valve stenosis and needs a referral to a cardiologist D. A client who has asthma and is being discharged to home
B
A nurse is preparing to suction a client's oral airway. Which of the following devices or methods should the nurse use? A. In-line suctioning B. Yankauer catheter C. Bulb syringe D. Open suctioning
B
A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the nurse take? A. Suction for 30 seconds with each pass B. Allow 2 min in between suctioning to reoxygenate the lungs C. Use a rotating motion when inserting the catheter from the tracheostomy D. Set the suction pressure to 180mmHg
B
A nurse is providing teaching for a client who has a new prescription for a CPAP machine to treat obstructive sleep apnea. Which of the following should the nurse include? A. "Use the CPAP mask during the daytime." B. "Cover your nose with the CPAP mask." C. "Medications to assist with breathing can be administered through the CPAP machine." D. "You will need supplemental oxygen to use the CPAP machine."
B
A nurse is providing teaching for a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include? A. "Exhale into the incentive spirometer." B. "Use the incentive spirometer every hour while awake." C. "Hold your breath for 10 seconds when using the incentive spirometer." D. "Use the incentive spirometer two times each session."
B
A nurse is reviewing laboratory results for a client and notes the following ABG values: pH 7.31, PaCO2 49mmHg, and HCO3 25mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis
B
A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity? A. The volume of air inspired and expired with a regular breath B. The maximum volume of air that is expired after a maximum inspiration C. The amount of additional air that can be inspired after a regular inspiration D. The amount of air in the lung after maximal inspiration
B
A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature 100.4F B. PaO2 50mmHg C. Rhonchi D. Hypopnea
B
A nurse receives a shift report on four adult clients who are between the ages of 25 and 55. Which client should the nurse assess first? a)Male client with a hemoglobin of 15.9 (160 mmol/L) b)Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 c) Female client taking daily calcium supplements with a serum calcium level of 9.4 (2.35 mmol/L) d)Male client with a blood urea nitrogen (BUN) of 20 (7.1 mmol/L) and a creatinine of 1 (96 mcmol/L)
B
An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? a)Pant using rapid, shallow breaths b)Breathe into cupped hands c)Use a rapid deep-breathing technique d)Hold the breath for as long as possible
B
To determine the presence of respiratory alkalosis in the laboring client, what should the nurse evaluate her for? a)A change in the respiratory rate. b)A tingling sensation in the hands. c)Periodic changes in the fetal heart rate. d)A pulse oximetry reading of less than 98%.
B
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? SATA A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in water seal chamber with inspiration and expiration D. Exposed sutures without dressing E. Drainage system upright at chest level
B C
A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? SATA A. Assist control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation
B C D
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated BP
B E
A 9-year-old child with type 1 diabetes is admitted to the hospital with deep, rapid respirations; flushed, dry cheeks; abdominal pain with nausea; and increased thirst. What laboratory findings is the nurse most likely to observe? a)pH 7.25, glucose 60 mg/dL b)pH 7.5, glucose 60 mg/dL c)pH 7.25, glucose 460 mg/dL d)pH 7.5, glucose 460 mg/dL
C
A child has been admitted to the pediatric unit with a severe asthma attack. What type of acid-base imbalance should the nurse expect the child to develop? a)Metabolic alkalosis caused by excessive production of acid metabolites b)Respiratory alkalosis caused by accelerated respirations and loss of carbon dioxide c)Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid d) Metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid formation
C
A client is admitted to the ED following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus
C
A client is brought to the emergency department after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse suspect to assess in this client? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
C
A nurse is assessing a client 5hr after the insertion of a chest tube that is attached to a water-seal drainage system. Which of the following observations about the drainage should the nurse report to the provider? A. 400mL drainage since insertion B. A gush of fluid when repositioning the client C. About 150mL./hr drainage over the past 2hr D. Significant decrease in drainage over the past 3 hr
C
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal BP 104/72mmHg, HR 116/min with regular rhythm, and respiratory rate 42/min and deep. Which of the following arterial blood gas findings should the nurse expect? A. pH 7.68, PaO2 96mmHg, PaCO2 38mmHg, HCO3 28mEq/L B. pH 7.48, PaO2 100mmHg, PaCO2 28mmHg, HCO3 23 mEq/L C. pH 6.98, PaO2 100mmHg, PaCO2 30mmHg, HCO3 18 mEq/L D. pH 7.58, PaO2 96mmHg, PaO2 96mmHg, PaCO2 38mmHg, HCO3 29mEq/L
C
A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which potential complication of hyperventilation? a)Tetany b)Hypercapnia c)Respiratory alkalosis d)Metabolic acidosis
C
A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first? A. Auscultate the lung sounds B. Document the respiratory rate C Obtain oxygen saturation D. Check the capillary refill
C
A nurse is caring for a client who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flange of the outer cannula? A. Commercially prepared transparent dressing B. Cotton-filled gauze square C. Commercially prepared fenestrated dressing D. Twill tape
C
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? A. Urine negative for ketones B. Distended neck veins C. Kussmaul respirations D. Elevated BP
C
A nurse is caring for a client who has the following ABG values: pH 7.44, PaCO2 37mmHg, and HCO3 24mmHg. The nurse should identify that these values are an indication of which of the following? A. Metabolic acidosis B. Respiratory acidosis C. Acid-base balance D. Respiratory alkalosis
C
A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27mmHg, and HCO3 25mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis
C
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."
C
A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy? A. Poor skin turgor B. Copious respiratory secretions C. Cracks in the oral mucosa D. Elevated heart rate
C
A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client? A. Simple face mask B. Nasal cannula C. Venturi mask D. Face tent
C
A nurse is caring for a toddler with severe dehydration and its associated acid-base imbalance. What compensatory mechanism within the body is activated to counteract the effects of the child's acid-base imbalance? a)Profuse diaphoresis b)Increased temperature c)Increased respiratory rate d)Renal retention of hydrogen ions
C
A nurse is monitoring a client who has metabolic acidosis after interventions have been initiated. Which step of the nursing process is next? A. Assessment B. Planning C. Evaluation D. Implementation
C
A nurse is planning care for a client following placement of a chest tube 1hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8hr
C
A nurse is preparing to transport a client who has a chest tube and a closed-chest wet-suction drainage system to radiology. Which of the following actions should the nurse take when detaching the suction source for transportation? a. clamp the chest tube B milk the chest tube C. Make sure the air vent is open D Empty the collection chamber
C
A nurse is reviewing the ABG values for a client and notes the following results: pH 7.49 PaCO2, 39mmHg, and HCO3 35mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis
C
A nurse is reviewing the latest ABG values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process? A. Planning B. Assessment C. Evaluation D. Implementation
C
A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take? A. Use clean techniques to perform the procedure B. Apply suction when inserting the catheter C. Administer 100% oxygen before the procedure D. Suction the tracheostomy for 20 seconds each time
C
The nurse is caring for a client who is being discharged after recovering from ARDS. The family asks whether the client is out of danger and whether normal activities can be resumed. Which explanation will the nurse provide to the client and family? A. "The client is out of danger and can resume normal activities." B. "The client will be ready for normal routines in about a year." C. "The client will need to tailor activities until maximal respiratory function returns." D. "The client will never recover fully."
C
A client comes to the ED in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion
D
A nurse has completed assessing and analyzing data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next? A. Implementation B. Reassessment C. Evaluation D. Planning
D
A nurse in the emergency department is assessing a client who has deep, rapid respirations. ABG analysis includes the following values: pH 7.25, PaCO2 40, and HCO3 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis
D
A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take? A. Instruct the client to lie prone with arms by the sides B. Complete a surgical checklist on the client C. Remind the client that there is minimal discomfort during the removal process D. Place an occlusive dressing the site once the tube is removed
D
A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? A. Place the drainage system at the head of the client's bed B. Increase the suction to the chest drainage system C. Place the client on low-flow oxygen via nasal cannula D. Immerse the end of the chest tube in a bottle of sterile water
D
A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis? A. Lymphatic fluid B. Oxygenated blood C. Synovial fluid D. Surfactant
D
A nurse is caring for a client who is 6hr postoperative and has a chest tube in place that is attached to a closed-chest water-seal drainage system. The nurse should identify that which of the following is an indication of a problem in the drainage system? A. Constant bubbling in the suction-control chamber B. Fluctuations in the fluid level in the water-seal chamber C. Occasional bubbling in the water-seal chamber D. Continuous bubbling in the water-seal chamber
D
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? A. Apply a vest restraint if self-extubation is attempted B. Monitor ventilator settings every 8hr C. Document tube placement in centimeters at the angle of the jaw D. Assess breath sounds every 4hr
D
A nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. The client reports a lightheaded feeling and tingling of the fingers. Which of the following actions should the nurse take? A. Instruct the client to hold her breath and bear down B. Ensure that the client's breathing rate is more than twice her normal rate C. Apply counter-pressure to the client's lower back D. Have the client breathe into a paper bag
D
A nurse is caring for a client who requires 7L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use? A. Nasal cannula B. nonrebreather mask C. Partial rebreather mask D. Simple face mask
D
A nurse is caring for a client who requires a chest tube. The provider asks for the suction pressure of the closed-chest drainage system to be set at -40cm of water. Which of the following closed-chest drainage systems should the nurse prepare for this client? A. Pneumostat B. Water-seal system C. Heimlich valve D. Dry suction-control system
D
A nurse is caring for a client who sustained trauma to the head and neck and will require long-term airway support. Which of the following pieces of equipment will be required for home health care for this client? A. Nasopharyngeal airway device B. Oropharyngeal airway device C. Endotracheal tube D. Tracheostomy tube
D
A nurse is obtaining ABG for a client who has vomited for 24 hr. The nurse should expect which of the following acid-base balances to result from vomiting for 24 hr? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
D
A nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the right A. starts the flow of oxygen B. provides the maximal oxygen flow C. provides a minimal oxygen flow D. Stops the flow of oxygen
D
A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space
D
A nurse is reviewing a client's latest ABG report. Which of the following values should the nurse identify as the priority to report to the provider? A. pH 7.37 B. PaCO2 43mmHg C. HCO3 27mEq/L D. PaO2 76mmHg
D
A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis
D
A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3 22mEq/L, PaCO2 50mmHg B. pH 7.48, HCO3 23mEq/L, PaCO2 25mmHg C. pH 7.32, HCO3 18mEq/L, PaCO2 40 mmHg D. pH 7.49, HCO3 32 mEq/L, PaCO2 40mmHg
D
A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following laboratory values is consistent with diabetic ketoacidosis? A. Blood glucose 30mg/dL B. Negative urine ketones C. Blood pH 7.38 D. Bicarbonate level 12 mEq/L
D
A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions should the nurse plan to take? A. Hyperoxygenate the client before disconnecting the ventilator B. Apply suction pressure while advancing the catheter C. Wear a face shield during the procedure D. Reuse the catheter repeatedly
D
A nurse should recognize that which of the following findings is an indication for oxygen therapy? A. Respiratory rate 32/min B. PaO2 90mmHg C. Fraction of inspired oxygen (FiO2) 65% for 4 days D. Oxygen saturation SaO2 90%
D
Surgery is performed on a client with a parotid tumor. Postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take? a)Administer a potent diuretic b)Obtain a prescription for an alkalinizing agent c)Have the client breathe into a rebreather bag at a slow rate d)Encourage the client to cough and take deep breaths between coughs
D
While reviewing the laboratory results of a client in an acute care setting, the nurse finds urine output of 250 mL in 24 hours, blood osmolality of 310 milliosmoles per kg, and a systolic blood pressure of 90 mm Hg. What is the priority nursing intervention in this situation? a)Consider it as a normal finding. b)Advise the client to drink 2 to 3 L of water daily. c)Assess the creatinine and blood urea nitrogen (BUN) levels d)Request an increase in the intravenous fluid rate from the healthcare provider.
D
A nurse is assessing a client who has pancreatitis. The client's ABG reveal metabolic acidosis. Which of the following are expected findings? SATA A. Tachycardia B .Hypertension C. Bounding Pulses D. Hyperreflexia E. Dyrhytmia F. Tachypnea
E F
metabolic acidosis or alkalosis: Client takes long, deep breaths
Metabolic Acidosis
Which acid-base imbalance is caused by this condition? hyperventiliation
Respiratory alkalosis
A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to an LPN
c
metabolic acidosis or alkalosis: Antacid overuse is a causative factor
metabolic alkalosis
Which acid-base imbalance is caused by this condition? heavy exercise, seizure activity, hypoxia
lactic acidosis
dysrhythmias bradycardia weak peripheral pulses hypotension tachypnea headache drowsiness, confusion Kussmaul respirations warm, dry, pink skin
manifestations of metabolic acidosis
Tachycardia Normotensive or hypotension Atrial tachycardia, ventricular issues Numbness, tingling, tetany, muscle weakness, hyperreflexia, confusion, convulsion Depressed skeletal muscles resulting in ineffective breathing
manifestations of metabolic alkalosis
initial tachycardia, hypertension, changes to bradycardia and hypotension as condition worsens V-Fib anxiety, irritability, confusion, lethargy, coma Ineffective, shallow, rapid breathing Pale, cyanotic skin
manifestations of respiratory acidosis
Tachypnea Inability to concentrate Numbness, tingling Tinnitus loss of consciousness Tachycardia, ventricular and atrial dysrthymias Rapid, deep respirations
manifestations of respiratory alkalosis
Which acid-base imbalance is caused by this condition? Diabetic ketoacidosis
metabolic acidosis
Which acid-base imbalance is caused by this condition? Diarrhea
metabolic acidosis
Which acid-base imbalance is caused by this condition? Excess production of hydrogen ions
metabolic acidosis
Which acid-base imbalance is caused by this condition? Excessive intake of acids (ethyl alcohol, methyl alcohol, aspirin)
metabolic acidosis
Which acid-base imbalance is caused by this condition? Starvation
metabolic acidosis
Which acid-base imbalance is caused by this condition? kidney failure, severe lung problems (inadequate elimination of hydrogen ions)
metabolic acidosis
Which acid-base imbalance is caused by this condition? liver failure
metabolic acidosis
Which acid-base imbalance is caused by this condition? pancreatitis
metabolic acidosis
metabolic acidosis or alkalosis: Low pH and low bicarbonate
metabolic acidosis
metabolic acidosis or alkalosis: Severe diarrhea that leads to bicarbonate loss is a causative factor
metabolic acidosis
pH: 7.32 PaO2: 88 mm Hg PaCO2: 38 mm Hg HCO3: 19 mEq/L
metabolic acidosis
Which acid-base imbalance is caused by this condition? Digoxin toxicity
metabolic alkalosis
Which acid-base imbalance is caused by this condition? Potassium depletion (diuretics, laxative overuse, Cushing's syndrome, hyperaldosteronism)
metabolic alkalosis
Which acid-base imbalance is caused by this condition? Prolonged vomiting
metabolic alkalosis
Which acid-base imbalance is caused by this condition? base excess
metabolic alkalosis
Which acid-base imbalance is caused by this condition? blood transfusions, TPN, sodium bicarbonate administration
metabolic alkalosis
Which acid-base imbalance is caused by this condition? nasogastric suction
metabolic alkalosis
Which acid-base imbalance is caused by this condition? oral ingestion of excess antacids
metabolic alkalosis