NUR 200 1.4 Review: Respiratory Acidosis
The nurse is providing care to a client with pulmonary edema who is diagnosed with respiratory acidosis. Which arterial blood gas (ABG) finding supports this diagnosis? PaCO2 38 mmHg pH 7.40 pH 7.21 PaCO2 42 mmHg
pH 7.21 Rationale Respiratory acidosis is characterized by pH less than 7.35 and PaCO2 greater than 45 mmHg on an ABG. In metabolic acidosis, pH is less than 7.35 but PaCO2 is less than 45 mmHg. Alkalosis is characterized by pH greater than 7.35.
The nurse is caring for a client with a history of excessive snoring and breath sounds that indicate diffuse wheezing. The client's laboratory data indicate respiratory acidosis. The nurse suspects which as the likely cause of the client's acid-base imbalance? Neuromuscular disease Opiate overdose Airway obstruction Chest trauma
Airway obstruction Rationale Breathing problems such as diffuse wheezing and excessive snoring are indicators of airway obstruction, which can cause respiratory acidosis. There is no evidence for opiate overdose, chest trauma, or neuromuscular disease in the client.
The nurse is monitoring an intubated client who has severe respiratory acidosis. The nurse understands that the PaCO2 level for the client should be lowered slowly to prevent which potential problem? Cardiovascular complications Increased oxygen saturation Carbon dioxide narcosis Removal of respiratory secretions
Cardiovascular complications Rationale The PaCO2 level for the intubated client should be lowered slowly to prevent cardiovascular complications. Carbon dioxide narcosis can occur if supplemental oxygen is delivered too quickly. Removal of respiratory secretions and increased oxygen saturation are not complications of decreasing PaCO2 levels.
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD) who is admitted to the unit with respiratory acidosis. Which assessment finding supports this diagnosis? Headache Cool skin Heart rate of 62 Blood pressure of 110/60
Headache Rationale The client with respiratory acidosis will exhibit a headache. Warm skin and increased heart rate would also indicate respiratory acidosis. Blood pressure is not affected by this condition.
The student nurse is assisting in the care for a client with acute respiratory acidosis. The nurse explains to the student nurse that the client's blood pH initially falls in the development of acute respiratory acidosis because of which process? Hypoventilation Vasodilation Papilledema Hypercapnia
Hypoventilation Rationale Hypoventilation causes the partial pressure of carbon dioxide to fall in the blood, causing an initial drop in blood pH. Hypercapnia, or increased carbon dioxide levels, develops later as the body compensates for the decreased pH. Hypercapnia then causes papilledema (swelling of the optic nerve) and peripheral vasodilation.
The nurse is monitoring the input and output of a client with respiratory acidosis. The nurse understands that this intervention addresses which potential problem in the client? Increased risk of injury Potential for dehydration Increased risk for mental status changes Potential for compromised airway
Potential for dehydration Rationale Clients with respiratory acidosis are at risk for dehydration, so monitoring the input and output of a client addresses this potential problem. Monitoring input and output does not address the risk for mental status changes, potential for compromised airway, or risk of injury.
The nurse is caring for a client diagnosed with respiratory acidosis. Which interventions are aimed at maintaining airway patency? Encouraging ambulation as tolerated Encouraging fluid intake Providing oral suctioning as needed Assessing neurological function Administering inhaled bronchodilators as ordered
Providing oral suctioning as needed Administering inhaled bronchodilators as ordered Rationale Providing oral suctioning to clear respiratory secretions and administering inhaled bronchodilators to open airways help maintain airway patency. Encouraging fluid intake, assessing neurological function, and encouraging ambulation are appropriate interventions, but they do not help maintain airway patency.
The nurse is assessing a client with suspected respiratory acidosis. Which assessment items are priority for the nurse to collect? (Select all that apply.) Rate and depth of respirations Skin color and temperature Presence of sinus pain Appearance of sclera Appearance of the optic nerve
Rate and depth of respirations Skin color and temperature Appearance of the optic nerve Rationale Priority assessments for a client suspected of respiratory acidosis would be skin color and temperature, appearance of the optic nerve (assessing for papilledema), and rate and depth of respirations. The nurse would be less concerned with the external appearance of the eye and the presence of sinus pain.
The nurse is administering sodium bicarbonate to the client with respiratory acidosis. The nurse understands that which is the primary goal of treatment for this client? Removing excess acids in blood Decreasing pH of blood Opening airways Increasing carbon dioxide in blood
Removing excess acids in blood Rationale The primary goal of treatment for respiratory acidosis is to remove excess acids and increase pH to normal levels. Increasing carbon dioxide in blood will only decrease pH further. Opening the airways is another method of returning blood pH to normal, but is not the ultimate goal of treatment.
The nurse is reviewing the medication orders for a client with acute respiratory acidosis caused by a narcotic overdose. Which medications would the nurse anticipate being prescribed for the client? (Select all that apply.) Anesthetics Sodium bicarbonate Naloxone Bronchodilators Antibiotics
Sodium bicarbonate Naloxone Bronchodilators Rationale Sodium bicarbonate is administered to remove excess acids and increase 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.
The nurse is evaluating a client recovering from respiratory acidosis. Which observation made by the nurse indicates that the client is achieving treatment goals? The client has shallow respirations. The client is adequately hydrated. The client has a pH less than 7.35. The client has an oxygen saturation level > 85%.
The client is adequately hydrated. Rationale Treatment goals for the client with respiratory acidosis include normal respiration, hydration status, and PaCO2, pH, and oxygen saturation levels. The pH and oxygen saturation levels given are too low, and shallow respirations are not normal.
The nurse is assessing a client with acute respiratory acidosis caused by pneumonia. Which findings would the nurse expect when examining the client? (Select all that apply.) 6Warm, flushed skin Blurred vision Impaired memory Weakness Elevated pulse rate
Warm, flushed skin Blurred vision Elevated pulse rate Rationale The client with acute respiratory acidosis will have warm, flushed skin, an elevated pulse rate, and blurred vision. The client with chronic, not acute, respiratory acidosis will have weakness and impaired memory.