AH2 Adaptive Quizzing
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the result of which laboratory test to evaluate the client for hypoxia? a. Red blood cell count b. Sputum culture c. Arterial blood gas d. Total hemoglobin
c. ABG Red blood cell count, sputum, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.
A client with chest trauma is admitted to the emergency department. Which intervention takes priority? a. Ensure patent airway. b. Monitor the cardiac rhythm. c. Release dressing in the tension pneumothorax. d. Anticipate intubation for respiratory distress
A. Ensure patent airway. Ensuring the client has a patent airway supports the primary intervention of prioritizing care for a client with chest trauma. The nurse should ensure that the client is getting sufficient air for respirations. Monitoring the cardiac rhythm is done after obtaining a patent airway. This follows the ABC's of emergency management. Release of dressing in tension pneumothorax is usually done to monitor the wound after a sucking chest wound is covered.
The nurse is caring for a client who is hyperventilating. The nurse recall the client is at risk for what? a. Respiratory acidosis b. Respiratory alkalosis c. Respiratory compensation d. Respiratory decompensation
B. Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess carbon dioxide retained in the lungs from conditions such as hypoventilation or COPD. Respiratory compensation and decompensation are terms not associated with this situation.
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? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
a: Metabolic acidosis 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.
A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and the HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? a. Airway obstruction b. Inadequate nutrition c. Prolonged gastric suction d. Excessive mechanical ventilation
d: Excessive mechanical ventilation The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.
The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis? a. PCO2: 49, HCO3: 32, pH: 7.50 b. PCO2: 26, HCO3: 20, pH: 7.52 c. PCO2: 54, HCO3: 28, pH: 7.30 d. PCO2: 28, HCO3: 18, pH: 7.28
d: PCO2: 28, HCO3: 18, pH: 7.28 Decreased pH and bicarbonate values reflect metabolic acidosis (seen in DKA); a decreased PCO2 values indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased PCO2 value indicates compensatory hypoventilation. Increased pH and decreased PCO2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased PCO2 values reflect hypoventilation and respiratory acidosis.
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? a. Bradycardia b. Restlessness c. Constricted pupils d. Clubbing of the fingers
B. Restlessness Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.
A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time? a. Prepare the client for emergency surgery. b. Facilitate the client's verbal communication. c. Assess the client's response to the interventions. d. Maintain sterility of the ventilation system that is being used.
C. Assess the client's response to the interventions. If a client is not responding to interventions, the plan must be changed to support respiration. Preparing the client for emergency surgery is presumptive; there are insufficient data to conclude that surgery is necessary. Endotracheal intubation does not permit verbal communication. Maintaining sterility of the ventilation system that is being used is important, but not the priority.
On admission to the ICU, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? a. Muscle twitching b. Mental instability c. Deep and rapid respirations d. Tachycardia and cardiac dysrhythmias
C. Deep and rapid respirations Deep rapid respirations are an adaptation to a decreased serum pH. Carbonic acid dissociates in the lungs to hydrogen ions and carbon dioxide, which helps increase the serum pH. Muscle twitching results from low serum calcium, not compensated metabolic acidosis. Mental confusion does not occur in compensated acidosis; confusion can occur in uncompensated metabolic acidosis. Tachycardia and cardiac dysthymias are associated with hyperthyroidism, not compensated metabolic acidosis.
A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? a. Report of pain when taking deep breaths b. Client is observed splinting the fractured site c. Diminished breath sounds on the affected side d. Bowel sounds are auscultated in the lower chest
C. Diminished breath sounds on the affected side Fractured ribs may penetrate the pleura and lung, allowing air to fill the pleural space and collapse the lung, causing diminished breath sounds. This is a complication of fractured ribs. Reports of pain when taking deep breaths is an expected response to tissue trauma caused by a fractured rib. Observing the client splinting the fracture site is an expected response to tissue damaged caused by a fractured rib. Bowel sounds auscultated in the lower chest suggest rupture of the diaphragm, not fracture ribs.
A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? a. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. b. Asses the need for suctioning when the high-pressure alarm of the ventilator is activated. c. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. d. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.
B. Asses the need for suctioning when the high-pressure alarm of the ventilator is activated. The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. Cuff should be inflated; it does not need to be tested this often. Humidification should occur, but the temperature should not be routinely changed. Regulating the PEEP according to the rate and depth of the client's respirations is a dependent function of the nurse and cannot be implemented without a healthcare provider's prescription.
A client's arterial blood gas report indicates that pH is 7.25, PCO2 is 60 mm Hg, and HCO3 is 26 mEq/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 65-year-old with pulmonary fibrosis The low pH and elevated PCO2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impeded 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 body. 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 with experience metabolic alkalosis from an excess of base bicarbonate.
A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do? a. Hyperoxygenate with 100% oxygen before and after suctioning b. Suction two or three times in quick succession to remove secretions c. Use the technique of short, pushing movements when applying suction d. Apply suction for no more than 10 seconds while inserting the catheter
A. Hyperoxygenate with 100% oxygen before and after suctioning Suctioning removes not only secretions but also oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after. Suction should be performed only as needed to maintain a patent airway; excessive suctioning irritates the mucosa, which increases secretion production. Short pushing movements can cause tracheal damage. To prevent trauma to the trachea, suction should be applied only while removing the catheter, not while inserting.
After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? a. Pink b. Clear c. Green d. Yellow
A. Pink With a pulmonary embolus, there is partial or complete occlusion of pulmonary flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.
A client who is prescribed diuretic therapy develops metabolic alkalosis. To which intervention should the nurse give priority as the healthcare team corrects the alkalosis? a. Preventing falls b. Monitoring electrolytes c. Administering antiemetics d. Adjusting the diuretic therapy
A. Preventing falls Preventing falls is the priority nursing intervention as the healthcare team corrects the alkalosis. A client with alkalosis has hypotension and muscle weakness, which increases the risk for injury due to falls. Monitoring electrolytes and adjusting diuretic therapy requires prescriptive authority and are important actions primarily managed by the healthcare provider. Antiemetics are prescribed by the healthcare provider wi=hen there is nausea and vomiting. Although nurses have an important role in assisting the healthcare team with implementing prescriptions, preventing falls is the priority within the nursing scope of practice and does not require a prescription
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? a. An obese client with leg trauma b. A pregnant client with acute asthma c. A client with diabetes who has cholecystitis d. A client with pneumonia who is immunocompromised.
A. An obese client with leg trauma An obese client with leg trauma has two risk factors for development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for development of pulmonary embolism.
A nurse is caring for several clients in the ICU. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome? a. Aspirating gastric contents b. Getting an opioid overdose c. Experiencing an anaphylactic reaction d. Receiving multiple blood transfusions
A. Aspirating gastric contents Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes, which release inflammatory mediators; the process progresses to pulmonary edema, vascular narrowing and obstruction, pulmonary hypertension, and impaired gas exchange. Getting an opioid overdose is not as common as a cause of ARDS as is aspiration pneumonia; this more likely will cause depressed respirations. Although anaphylaxis may cause ARDS, it is not a common cause. Although multiple blood transfusions have been known to precipitate ARDS, they are not an common cause.
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 a. Headache b. Irritability c. Restlessness d. Hypertension e. Lightheadedness
Answer: A, B, C (headache, irritability, restlessness) .... Think acidosis! Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis. 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.
What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply a. Crackles b. Atelectasis c. Hypoxemia d. Severe dyspnea e. Increased pulmonary wedge pressure
Answer: a, b, c, d Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin.
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, and a serum potassium level of 3.8 mEq/L. The nurse concludes that the findings support what diagnosis? a. Hypocapnia b. Hyperkalemia c. Metabolic alkalosis d. Respiratory acidosis
C. Metabolic alkalosis 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, no hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mE1/L. With respiratory acidosis the pH will be less than 7.35.
A nurse is caring for client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
C. Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increase carbon dioxide level leads to respiratory acidosis. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression of excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
The nurse is caring for a client with the following ABG values: PO2 89 mm HG, PCO2 35 mm Hg, and pH or 7.37. These findings indicate that the client is experiencing which condition? a. Respiratory alkalosis b. Poor oxygen perfusion c. Normal acid-base balance d. Compensated metabolic acidosis
c: Normal acid-base balance All data are within expected limits; PO2 is 80 to 100 mm Hg, PCO2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen is within the expected limits of 80 to 100 mm Hg. With metabolic acidosis, the pH is less than 7.35. With respiratory alkalosis, the pH is greater than 7.45.
The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply a. "I should assess for low blood pressure." b. "I should assess for increased digitalis toxicity." c. "I should assess for a decreased rate of ventilation in respiratory alkalosis." d. "I should assess for an increased depth of ventilation in respiratory alkalosis." e. "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis."
Answer: a, b, c The nurse should assess for low blood pressure and increased digitalis toxicity as cardiovascular manifestations of alkalosis, not respiratory manifestation. The nurse should assess for increased rate of ventilation in respiratory alkalosis. The nurse should assess for increased depth of ventilation in respiratory alkalosis. It is imperative that the nurse check for decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis.
A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer
C. Administer oxygen using a face mask The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted. The client is n not experiencing a cardiac arrest, and therefore a code should not be initiated. After more definitive medical intervention, deep breathing and coughing or use of an incentive spirometer may be done to prevent or treat atelectasis.
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? a. Hypertension b. Tenacious sputum c. Altered mental status d. Slowed rate of breathing
C. Altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of cardiac hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing is fast and shallow.
A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? a. An elevated pH, elevated PCO2 b. A decreased pH, elevated PCO2 c. An elevated pH, decreased PCO2 d. A decreased pH, decreased PCO2
C. An elevated pH, decreased PCO2 In respiratory alkalosis the pH level is elevated because of the loss of hydrogen ions; the PCO2 level is low because the carbon dioxide is lost through hyperventilation. An elevate pH, elevated PCO2 is partially compensated metabolic alkalosis. A decreased pH, elevated PCO2 is respiratory acidosis. A decreased pH, decreased PCO2 is metabolic acidosis with some compensation
A client with 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? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
C. Respiratory acidosis 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 i s CO2 and the acceptable range of PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated
A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? a. Bradycardia b. Flushed face c. Unilateral chest pain d. Decreased blood pressure
C. Unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence the blood pressure.
A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent? a. Incisional pain b. Wound dehiscence c. Anastomosis leakage d. Pulmonary embolism
D Pulmonary embolism Immobility contributes to venous stasis, which can cause deep vein thrombosis and pulmonary embolism. Insufficient mobility does not contribute to incisional pain; incisional pain contributes to immobility. Stressors commonly associate with wound dehiscence include obesity, infection, and poor wound healing, not immobility. Anastomosis leakage occurs when gastrointestinal contents leak into the abdominal cavity; it is caused by leakage around, or separation of sutures or staples where the stomach is stapled or the loop of the jejunum is anastomosed to a new outlet from the stomach, or where it is attached to the proximal jejunum.
A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? a. Tetany b. Hypercapnia c. Metabolic acidosis d. Respiratory alkalosis
D. Respiratory alkalosis Increased rate and depth of breathing result in excessive elimination of co2, and respiratory alkalosis can result. Tetany is associated with hypocalcemia. With hyperventilation, CO2 levels will be decreased (hypocapnia), not elevated. Metabolic acidosis results from excess hydrogen ions caused by a metabolic problem, not a respiratory problem.
