Exam 4 Flashcards
ABGs, Atelectasis, Pneumonia,
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid–base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Increased PaCO2
D. Metabolic acidosis
B
Extreme anxiety can lead to hyperventilation, the most common cause of acute respiratory alkalosis. During hyperventilation, CO2 is lost through the lungs, creating an alkalotic state and a low PaCO2. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. Metabolic acidosis results from the loss of bicarbonate, not CO2.
The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results?
A. Respiratory acidosis with no compensation
B. Metabolic alkalosis with compensatory alkalosis
C. Metabolic acidosis with no compensation
D. Metabolic acidosis with compensatory respiratory alkalosis
D
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.
A nurse, who is orienting a newly licensed nurse, is planning care for a nephrology client. The nurse states, “A client with kidney disease partially loses the ability to regulate changes in pH.” What is the cause of this partial inability?
A. The kidneys regulate and reabsorb carbonicacid to change and maintain pH.
B. The kidneys buffer acids through electrolyte changes.
C. The kidneys reabsorb and regenerate bicarbonate to maintain a stable pH.
D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
C
The kidneys regulate the bicarbonate level in the extracellular fluid; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH, whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.
The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube was placed upon admission, and since that time the client has been on low intermittent suction. Upon review of the morning’s blood work, the nurse notices that the client’s potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance?
A. Hypercalcemia
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis
C
Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client’s respiratory status.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Metabolic acidosis
A
The pH is below 7.35, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range, so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis, but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.
The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation?
A. Endocarditis
B. Multiple myeloma
C. Guillain–Barré syndrome
D. Overdose of amphetamines
C
Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a client with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain–Barré syndrome. The other listed diagnoses are not associated with respiratory acidosis.
A medical nurse educator is reviewing a client’s recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
C. The kidneys react rapidly to compensate for imbalances in the body.
D. The kidneys regulate the bicarbonate level in the intracellular fluid.
B
The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by kidney disease. Renal compensation for imbalances is relatively slow (a matter of hours or days).
Diagnostic testing has been prescribed to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill client. What health problem often precedes normal anion gap acidosis?
A. Metastases
B. Excessive potassium intake
C. Water intoxication
D. Excessive administration of chloride
D
Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Based on these facts, the other listed options are incorrect.
The intensive care unit nurse is caring for a client who experienced trauma in a workplace accident. The client is reporting dyspnea because of abdominal pain. An arterial blood gas test reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3– 20 mEq/L. The nurse should recognize the likelihood of which acid–base disorder(s)?
A. Respiratory acidosis only
B. Respiratory acidosis and metabolic alkalosis
C. Respiratory alkalosis and metabolic acidosis
D. Respiratory acidosis and metabolic acidosis
D
Clients can simultaneously experience two or more independent acid–base disorders. This client has a pH value below normal, a PCO2 value above 45 mm HG, and a HCO3– value of less than 22 mEq/L, which is indicative of both respiratory acidosis and metabolic acidosis.
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?
A. Rapid onset of severe dyspnea
B. Inspiratory crackles
C. Bilateral wheezing
D. Cyanosis
A. Rapid onset of severe dyspnea
The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.
The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply.
A. Encouraging a liberal fluid intake B. Instructing the client to move the legs in a “pumping” exercise
C. Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day
D. Using elastic stockings, especially when decreased mobility would promote venous stasis
E. Applying a sequential compression device
A, B, D, E
The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a “pumping” exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.
Which is a potential complication of a low pressure in the endotracheal tube cuff?
A. Tracheal bleeding
B. Aspiration pneumonia
C. Tracheal ischemia
D. Pressure necrosis
B. Aspiration pneumonia
Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.
A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which results are consistent with this disorder?
A. pH 7.28, PaO2 50 mm Hg
B. pH 7.46, PaO2 80 mm Hg
C. pH 7.36, PaCO2 32 mm Hg
D. pH 7.35, PaCO2 48 mm Hg
A. pH 7.28, PaO2 50 mm Hg
ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
The nurse is caring for a client who is intubated for mechanical ventilation. Which intervention(s) will the nurse implement to reduce the client’s risk of injury? Select all that apply.
A. Provide oral hygiene.
B. Assess for a cuff leak.
C. Reduce pulling on ventilator tubing.
D. Monitor cuff pressure every 8 hours.
E. Position with head above the stomach level.
A, B, C, D, E
Maintaining the endotracheal or tracheostomy tube is an essential part of airway management. Oral hygiene is provided frequently because the oral cavity is a primary source of lung contamination in the client who is intubated. Assessing for a leak from the cuff of the endotracheal tube needs to be done at the same time as providing other respiratory care. Ventilator tubing should be positioned so that there is minimal pulling or distortion of the tube in the trachea which reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at 20 to 25 mm Hg. The head of the bed should be higher than the stomach to reduce the risk of aspiration.
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:
A. suctioning the tracheostomy tube frequently.
B. using a cuffed tracheostomy tube. C. using the minimal-leak technique with cuff pressure less than 25 cm H2O.
D. keeping the tracheostomy tube plugged.
C. using the minimal-leak technique with cuff pressure less than 25 cm H2O.
To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won’t prevent tracheal dilation. Use of a cuffed tube alone won’t prevent tracheal dilation. The tracheostomy shouldn’t be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
A. Hypotension, hyperoxemia, and hypercapnia
B. Hyperventilation, hypertension, and hypocapnia
C. Hyperoxemia, hypocapnia, and hyperventilation
D. Hypercapnia, hypoventilation, and hypoxemia
D. Hypercapnia, hypoventilation, and hypoxemia
The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
Which statements would be considered appropriate interventions for a client with an endotracheal tube? Select all that apply.
A. The cuff is deflated before the tube is removed.
B. Routine cuff deflation is recommended.
C. Cuff pressures should be checked every 6 to 8 hours.
D. Humidified oxygen should always be introduced through the tube.
E. Suctioning the oropharynx prn is not recommended.
A, C, D
The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. And must be maintained at 15- 2 mm Hg to prevent excess pressure , High cuff pressure leads to tracheal bleeding and other complications. Humidified oxygen should always be introduced through the tube. Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. It is recommended to provide oral hygiene and suction the oropharynx whenever necessary, the cough , glottic, pharyngeal ,and laryngeal reflexes are suppressed and the nurse needs to keep all airways clear for the client.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client’s condition?
A. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
B. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher.
C. The client exhibits restlessness and confusion.
D. The client exhibits bronchial breath sounds over the affected area.
A. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client’s condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client’s condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?
A. Intubate the client and control breathing with mechanical ventilation
B. Increase oxygen administration
C. Administer a large dose of furosemide (Lasix) IVP stat
D. Schedule the client for pulmonary surgery
A. Intubate the client and control breathing with mechanical ventilation .
A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
A. Negative pressure
B. Volume cycled
C. Time cycled
D. Pressure cycled
With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
The nurse is planning for the care of a client with acute tracheobronchitis. What nursing interventions should be included in the plan of care? Select all that apply.
A. Increasing fluid intake to remove secretions
B. Encouraging the client to rest Using cool-vapor therapy to relieve laryngeal and tracheal irritation
C. Giving 3 L fluid per day
D. Administering a opioid analgesic for pain
In most cases, treatment of tracheobronchitis is largely symptomatic. Cool vapor therapy or steam inhalations may help relieve laryngeal and tracheal irritation. A primary nursing function is to encourage bronchial hygiene, such as increased fluid intake and directed coughing to remove secretions. Fatigue is a consequence of tracheobronchitis; therefore, the nurse cautions the client against overexertion, which can induce a relapse or exacerbation of the infection. The client is advised to rest.
Which oxygen administration device has the advantage of providing a high oxygen concentration?
A. Nonrebreathing mask
B. Venturi mask
C. Catheter
D. Face tent
A. Nonrebreathing mask
The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.
The nurse is educating the client in the use of a mini-nebulizer. What should the nurse encourage the client to do? (Select all that apply.)
A. Hold the breath at the end of inspiration for a few seconds.
B. Cough frequently.
C. Take rapid, deep breaths.
D. Frequently evaluate progress.
E. Prolong the expiratory phase after using the nebulizer.
The nurse instructs the client to breathe through the mouth, taking slow, deep breaths, and then to hold the breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli, thereby increasing functional residual capacity. The nurse encourages the client to cough and to monitor the effectiveness of the therapy. The nurse instructs the client and family about the purpose of the treatment, equipment setup, medication additive, and proper cleaning and storage of the equipment.
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?
A. Respiratory rate of 16 breaths/minute
B. Oxygen saturation of 93%
C. Runs of ventricular tachycardia
D. Blood pressure remains stable
C. Runs of ventricular tachycardia
