unit 3

Question 1

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Which patterns did the nurse observe? Select all that apply.

Answer 1

Respirations that are increased in rate

Respirations that are abnormally deep

Question 2

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50, Pao2 of 90 mm Hg, Paco2 of 40 mm Hg, and bicarbonate of 35 mEq/L. When the nurse notifies the primary health care provider about these levels, the nurse would anticipate receiving from the PHCP which prescription for this client?

Answer 2

Discontinue nasogastric suctioning.

Question 3

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen’s test on the client. The nurse would perform the steps in which order to conduct an Allen’s test? Arrange the actions in the order that they would be performed. All options must be used.

Answer 3

Explain the procedure to the client.

Apply pressure over the ulnar and radial arteries.

Ask the client to open and close the hand repeatedly.

Release pressure from the ulnar artery.

Assess the color of the extremity distal to the pressure point.

Document the findings.

Question 4

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg, and HCO3– of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Answer 4

Respiratory alkalosis, compensated

Question 5

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply.

Answer 5

Tetany
Tingling
Numbness
Restlessness

Question 6

A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care, knowing that the client is at risk for the development of which type of acid-base imbalance?

Answer 6

Metabolic acidosis

Question 7

A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care, knowing that the client is at risk for the development of which type of acid-base imbalance?

Answer 7

Metabolic acidosis

Question 8

A client reports ingesting large amounts of oral antacids on a daily basis because of a gastric ulcer. The nurse plans care, knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Answer 8

Metabolic alkalosis

Question 9

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse would take which action to help the client experiencing this acid-base disorder?

Answer 9

Provide emotional support and reassurance.

Question 10

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38, Paco2 of 38 mm Hg, Pao2 of 86 mm Hg, and HCO3 of 23 mEq/L. What action would the nurse take in response to these results?

Answer 10

Continue to monitor the client.

Question 11

A client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding?

Answer 11

An increased pH and an increased HCO3–

Question 12

The nurse notes that a client’s arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Answer 12

Nausea
Confusion
Tachycardia
Light-headedness

Question 13

The nurse reviews a client’s arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition?

Answer 13

Respiratory acidosis, uncompensated

Question 14

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse would plan to carry out which prescribed measure as the most effective means to treat the problem?

Answer 14

Administer prescribed antibiotics.

Question 15

The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. The nurse monitors the client, expecting that which occurs with this type of respiration? Select all that apply.
Correction of bradypnea
Blowing off carbon dioxide
Correction of metabolic acidosis
Correction of an acid-base imbalance
Respiratory compensation
Stimulation of Cheyne-Stokes respirations

Answer 15

Blowing off carbon dioxide
Correction of metabolic acidosis

Correction of an acid-base imbalance

Respiratory compensation

Question 16

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis

Answer 16

Metabolic alkalosis

Question 17

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder would the nurse monitor for that could accompany the acid-base imbalance?

Answer 17

Hypokalemia

Question 18

Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance?

Answer 18

Respiratory alkalosis

Question 19

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which priority problem?

Answer 19

Metabolic alkalosis

Question 20

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Answer 20

Respiratory acidosis from inadequate ventilation

Question 21

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3– is 22 mEq/L. The nurse interprets the results as indicating which condition?

Answer 21

Respiratory acidosis without compensation

Question 22

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3– of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Answer 22

Respiratory alkalosis, compensated

Question 23

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas (ABG) values are pH = 7.53, Pao2 = 72 mm Hg, Paco2 = 32 mm Hg, and HCO3– = 28 mEq/L (28 mmol/L). Which conclusion about the client would the nurse make?

Answer 23

The client is probably hyperventilating.

Question 24

The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Paco2 is 50 mm Hg, and the bicarbonate (HCO3) level is 26 mEq/L. The nurse concludes that which acid-base disturbance is present in this client?

Answer 24

Respiratory acidosis

Question 25

A client’s blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply.

Answer 25

Lethargy
Headache
Weakness
Confusion

Question 26

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Answer 26

Respiratory acidosis from inadequate ventilation

Question 27

A client is about to have arterial blood gases drawn, and the nurse explains what an Allen’s test is. What comment shows that the client understands the nurse’s explanation?

Answer 27

This test is done to make sure my circulation is good.”

Question 28

A client with coronavirus-2019 (COVID-19) has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse would take which action?

Answer 28

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.

Question 29

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client would expect to note which signs/symptoms?

Answer 29

Decreased respiratory rate and depth

Question 30

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

Answer 30

Headache, restlessness, and confusion

Question 31

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

Answer 31

Light-headedness and paresthesias

Question 32

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

Answer 32

Apply a warm compress.

Question 33

The nurse notes that a client’s arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Answer 33

Nausea
Confusion
Tachycardia
Light-headedness

Question 34

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse would plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

Answer 34

Potassium

Question 35

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client’s respiratory status would avoid which action?

Answer 35

Encouraging the client to breathe slowly and shallowly

Question 36

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Answer 36

Potassium level of 3.0 mEq/L (3.0 mmol/L)

Question 37

The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse understands that what other extrapulmonary causes can lead to respiratory failure? Select all that apply.

Answer 37

Stroke
Sleep apnea
Opioid analgesics, sedatives, anesthetics

Question 38

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid–base disturbance?

Answer 38

Respiratory acidosis

Question 39

The client with a history of chronic lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder?

Answer 39

“Do you have a headache or become confused?”

Question 40

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care, knowing that what reaction is the most powerful regulator of acid-base balance?

Answer 40

Kidney

Question 41

The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client’s safety by carefully implementing which prescribed precaution?

Answer 41

Seizure precautions

Question 42

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse’s findings?

Answer 42

pH 7.25, Paco2 50 mm Hg

Question 43

The nurse is caring for a hospitalized client with chronic obstructive pulmonary disease who is retaining carbon dioxide (CO2). The nurse anticipates which physical response will initially occur?

Answer 43

The client’s arterial blood gas results will reflect acidosis.

Question 44

The nurse is caring for a client with metabolic alkalosis. The nurse plans care, knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply.

Answer 44

Cardiac
Nervous
Neuromuscular

Question 45

The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance?

Answer 45

Respiratory acidosis

Question 46

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3– is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Answer 46

Respiratory acidosis without compensation

Question 47

The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul’s respirations. The nurse plans care, understanding that the purpose of this type of breathing is to correct what imbalance?

Answer 47

Metabolic acidosis

Question 48

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse would plan time for which activity after the arterial blood specimen is drawn?

Answer 48

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes

Question 49

A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder?

Answer 49

Metabolic acidosis

Question 50

The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value would the nurse expect to note?

Answer 50

Potassium level of 5.2 mEq/L (5.2 mmol/L)

Question 51

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

Answer 51

An increased pH and an increased HCO3–

Question 52

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse’s findings?

Answer 52

pH 7.25, Paco2 50 mm Hg

Question 53

The nurse reviews a client’s arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse would interpret these values as an indication of which condition?

Answer 53

Respiratory alkalosis, uncompensated

Question 54

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions, knowing that as the client’s CO2 level rises, what will occur with the blood pH?

Answer 54

The pH will fall

Question 55

A patient in the ICU experiences difficulty breathing in during exercise following trauma to his sternum. Which muscle involved in respiration was likely injured in this patient, leading to this condition?

A) Diaphragm

B) Sternocleidomastoid

C) External intercostal

D) Scalene

Answer 55

B

Question 56

The nurse is explaining to a young patient with asthma how air is conducted from his nose through his airways to the alveoli in his lungs. Which of the following represents the correct order of airways?

A) Nasopharynx, oropharynx, trachea, bronchi, bronchioles

B) Trachea, nasopharynx, oropharynx, bronchi, bronchioles

C) Trachea, bronchi, bronchioles, nasopharynx, oropharynx

D) Oropharynx, nasopharynx, trachea, bronchioles, bronchi

Answer 56

A

Question 57

The nurse is explaining to a patient in the ICU who has experienced a pneumothorax the role of the alveoli in respiration. The nurse should mention that which of the following are present in the alveoli? Select all that apply.

A) Macrophages

B) Surfactant

C) Epiglottis

D) Bronchus

Answer 57

A B

Question 58

A premature infant is experiencing infant respiratory distress syndrome in the NICU. The nurse recognizes that this condition is most likely caused by which of the following?

A) Defective type I alveolar cells

B) An obstruction at the right bronchus

C) Negative intrapleural pressure

D) Immature type II alveolar cells

Answer 58

D

Question 59

A patient is experiencing poor perfusion in his right thorax as a result of suspected partially occluded arteries. Occlusion in which artery or arteries would cause this? Select all that apply.

A) Aorta

B) Internal mammary

C) Subclavian

D) Intercostal

Answer 59

B C D

Question 60

A patient in the ICU with chronic obstructive pulmonary disease has mucous secretions throughout her respiratory system. Her breathing is highly labored. What is the primary cause of her labored breathing?

A) Decreased airway resistance due to increased airway diameter

B) Excessive surfactant

C) Increased airway resistance due to decreased airway diameter

D) Increased lung compliance

Answer 60

C

Question 61

A patient with pulmonary edema is experiencing respiratory distress. The nurse recognizes that which factor affecting gas exchange is most likely responsible for the patients dyspnea?

A) Surface area available for diffusion

B) Thickness of the alveolar-capillary membrane

C) Partial pressure of alveolar gas

D) Solubility and molecular weight of the gas

Answer 61

B

Question 62

A patient is recovering from severe altitude sickness after a failed attempt to climb Mount Everest. Which factor affecting gas exchange was most likely responsible for the patients illness?

A) Surface area available for diffusion

B) Thickness of the alveolar-capillary membrane

C) Partial pressure of alveolar gas

D) Solubility and molecular weight of the gas

Answer 62

C

Question 63

A patient in the ICU with pneumothorax is experiencing a ventilation-perfusion imbalance. Which type of imbalance is the patient most likely experiencing?

A) Physiological shunt

B) Anatomical shunt

C) Alveolar dead space

D) Silent unit

Answer 63

D

Question 64

A patient in the ICU experiences an asthma attack after a guest brings her a flower arrangement. Stimulation of which receptors is most associated with the patients asthma attack?

A) Stretch receptors

B) Peripheral chemoreceptors

C) Irritant receptors

D) Juxtacapillary receptors

Answer 64

C

Question 65

The patient has experienced a mediastinal shift to the left. Several structures or functions will be compromised by this condition. What is the most significant effect?

A) Right lung will be compressed.

B) Cardiac output will be diminished.

C) Point of maximal impulse will be displaced.

D) Jugular venous distention will occur.

Answer 65

B

Question 66

The patient has experienced a mechanical obstruction of the lower trachea from a mucous plug. What is the priority nursing action?

A) Obtain arterial blood gas results.

B) Deep suction the patient.

C) Turn onto left side and elevate head.

D) Increase tidal volume on ventilator.

Answer 66

B

Question 67

The patient has experienced a toxic inhalation injury that has significantly damaged his type II alveolar cells. The nurse should expect to find which of the following?

A) Impaired gas exchange and atelectasis

B) Bronchospasm and wheezing

C) Laryngospasm and stridor

D) Eupnea and bradycardia

Answer 67

A

Question 68

The patient has experienced an acute embolus in the thorax. An embolus in which artery is most likely to significantly compromise gas exchange?

A) Left main bronchial artery

B) Right peripheral bronchial arteriole

C) Left peripheral pulmonary arteriole

D) Right main pulmonary artery

Answer 68

D

Question 69

The patient has suffered a stab wound to the chest, interrupting the integrity of the pleura with loss of negative pleural pressure and interruption of the contact between the visceral and parietal pleural surfaces. What is the most significant effect of this trauma?

A) Pleuritic chest pain

B) Displaced diaphragm

C) Crepitus over ribs

D) Compromised gas exchange

Answer 69

D

Question 70

The patient is recovering from acute pulmonary disease. The nurse is comparing his current assessment findings with older ones. What currently increased assessment finding would indicate achievement of therapeutic goals?

A) Pulmonary compliance

B) Effort of breathing

C) Pressure support

D) Airway resistance

Answer 70

A

Question 71

The patient is exhibiting poor gas exchange. Four factors influence gas exchange across the alveolar membrane. What condition related to the four factors could be interfering with gas exchange?

A) Oxygen at 100%

B) 35% of the alveoli are filled with fluid.

C) Oxygen delivered under pressure

D) Alveolar membranes are 0.3 microns thick.

Answer 71

B

Question 72

The patient is experiencing a ventilationperfusion mismatch and compromised gas exchange. Correcting ventilationperfusion mismatch entails what actions?

A) Decreasing anatomic dead space with intubation

B) Decreasing alveolar dead space with positive-pressure ventilation

C) Increasing alveolar perfusion with platelet therapy

D) Increasing apex ventilation with high tidal volumes

Answer 72

B

Question 73

The patient is in severe metabolic acidosis from diabetic ketoacidosis. Based on the oxyhemoglobin dissociation curve, what change in the plan of care does the nurse expect?

A) Reduction of inhaled oxygen as hemoglobin is fully saturated

B) Use of positive-pressure ventilation to improve alveolar expansion

C) Increase in inhaled oxygen as hemoglobin saturation is low

D) Increase in ventilation rate to help excrete carbon dioxide

Answer 73

C

Question 74

After a drug overdose, a patient has very slow and shallow respirations. What stimulation of chemoreceptors or lung receptors will result in an increase in respiratory rate?

A) Decreased carbon dioxide levels at central chemoreceptors

B) PaO2 less than 60 at peripheral chemoreceptors

C) Normal airway resistance perceived by stretch receptors

D) Lack of stimulation of irritant receptors

Question 75

A patient in the ICU is producing an increased amount of sputum and has a fever. The nurse suspects an infection. Which of the following characteristics of the patients sputum would indicate a bacterial infection, as opposed to a viral infection? Select all that apply.

A) Yellow

B) Clear

C) Blood-streaked

D) Green

E) Brown

F) White

Question 76

An older patient in the ICU has labored breathing and a history of smoking. The nurse suspects that he has chronic obstructive pulmonary disease (COPD). Which of the following signs would tend to confirm that the patient has COPD? Select all that apply.

A) Increased anterior-posterior diameter of the chest

B) The patient lying propped onto one side

C) Deviation of the trachea from the midline

D) Inspiration taking just as long as expiration

Question 77

A patient in the ICU with a history of smoking is having tests performed to assess his respiratory function. Which test would be best for measuring the oxygenation of this patients blood?

A) SaO2

B) Pulse oximetry

C) End-tidal carbon dioxide

D) pH

Question 78

A patient has arterial blood gas testing performed. Her PaO2 is 95 mm Hg, SaO2 is 90%, pH is 7.4, and HCO3 is 23 mEq/L. Which of these values should the nurse be most concerned about?

A) PaO2

B) HCO3

C) pH

D) SaO2

Question 79

A patient in her first trimester is in the ICU and is displaying signs of metabolic alkalosis. On speaking with the patient, the nurse learns that she has been experiencing much vomiting, diarrhea, and anxiety in the past week. The nurse should recognize that which of the following is the most likely cause of this acid-base imbalance?

A) Pregnancy

B) Diarrhea

C) Vomiting

D) Anxiety

Question 80

A patient has arterial blood gas testing performed. His PaO2 is 83 mm Hg, SaO2 is 91%, pH is 7.5, PaCO2 is 24 mm Hg, and HCO3 is 22 mEq/L. Which of the following indicates this patients condition?

A) Respiratory acidosis with normal saturation (uncompensated)

B) Metabolic alkalosis with low saturation (uncompensated)

C) Respiratory alkalosis with low saturation (uncompensated)

D) Metabolic alkalosis with low saturation (fully compensated)

Question 81

7. A patient in the ICU has just undergone arterial blood gas testing. Her results are as follows: PaO2 is 90 mm Hg, pH is 7.43, PaCO2 is 24, and HCO3 is 19 mEq/L. Which of the following indicates this patients condition?

A) Respiratory alkalosis, fully compensated

B) Respiratory acidosis, partially compensated

C) Metabolic alkalosis, fully compensated

D) Metabolic acidosis, partially compensated

Question 82

A patient in the ICU with pneumonia and on mechanical ventilation is suspected to have pulmonary embolus. Which diagnostic study would be best for assessing for this condition?

A) Chest radiography

B) Ventilation-perfusion scanning

C) Pulmonary angiography

D) Bronchoscopy

Question 83

A patient in the ICU is suspected of having tuberculosis. The nurse understands that which diagnostic test will most likely be performed on this patient to confirm this suspicion?

A) Sputum culture

B) Thoracentesis

C) Ventilation-perfusion scanning

D) Pulmonary angiography

Question 84

The nurse is completing a history on a patient with dyspnea. What characteristic of dyspnea is most indicative of pulmonary disease?

A) Most severe when patient is supine

B) Awakens patient from sleep at night

C) Accompanied by anginal chest pain

D) Most severe with exertion

Question 85

During the inspection phase of the physical examination, the nurse notices that the patients chest wall is round, and the anterior-to-posterior diameter and the lateral diameter are equal. Based on this information, what disease process does the nurse suspect?

A) Lobular pneumonia

B) Chronic obstructive pulmonary disease

C) Acute respiratory distress syndrome

D) Respiratory syncytial virus

Question 86

The nurse is caring for a patient who has undergone thoracic surgery. What assessment information would best support the nurses suspicion of pulmonary consolidation?

A) Vesicular lung sounds at bases

B) Bronchial breath sounds over upper airway

C) Egophony at left posterior base of lung

D) Basal crackles that clear with cough

Question 87

A patient is being monitored with continuous pulse oximetry. Under what circumstance would the nurse question the accuracy of the pulse oximetry reading?

A) The patient is a victim of a fire in an enclosed space.

B) Cardiac monitor pattern shows normal sinus rhythm.

C) Extremities are warm and dry with intact pulses.

D) Respiratory rate and pulse rate are elevated.

Question 88

The patient is being monitored with an end-tidal CO2 monitor and has values trending upward. What acidbase abnormality should the nurse assess for?

A) Metabolic acidosis

B) Metabolic alkalosis

C) Respiratory acidosis

D) Respiratory alkalosis

Question 89

The patient has experienced a significant drop in hemoglobin levels and is slightly tachycardic. The pulse oximetry value is 100% and arterial blood gas values are normal. What is the most important adverse physiologic effect that the nurse would expect?

A) Polycythemia

B) Diminished blood pressure

C) Hyperalertness and hyperreflexia

D) Diminished tissue oxygenation

Question 90

The nurse is evaluating the following arterial blood gas values: pH 7.35, PaO2 95 mm Hg, SaO295%, PaCO2 40 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results?

A) Normal

B) Respiratory acidosis

C) Metabolic acidosis

D) Technical error

Question 91

The patient is experiencing respiratory acidosis. What nursing action is most likely to alleviate this condition?

A) Suction the endotracheal tube.

B) Reduce the respiratory rate on the ventilator.

C) Administer intravenous bicarbonate.

D) Increase the rate of crystalloid intravenous fluids.

Question 92

A patient has experienced a cardiopulmonary arrest and is receiving cardiopulmonary resuscitation. As the nurse evaluates the effectiveness of this therapy, what value on arterial blood gases is most indicative of hypoventilation?

A) Diminished PaO2

B) Diminished SaO2

C) Elevated HCO3

D) Elevated PaCO2

Question 93

A critically ill patient has arterial blood gas results of pH 7.6, PaCO2 40 mm Hg, and HCO3 30 mEq/L. With what medical situation do these results most clearly correlate?

A) Excess nasogastric drainage

B) Severe diarrhea

C) Diabetic ketoacidosis

D) Lobular pneumonia

Question 94

A patient has arterial blood gas results of pH 7.2, PaCO2 55 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results?

A) Metabolic acidosis

B) Metabolic alkalosis

C) Respiratory acidosis

D) Respiratory alkalosis

Question 95

A critically ill patient has arterial blood gas results of PaO2 60 mm Hg, SaO2 80%, pH 7.35, PaCO2 35 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results?

A) Hypoxemia and respiratory acidosis

B) Hypoxemia and normal acidbase balance

C) Normal oxygenation and metabolic acidosis

D) Normal oxygenation and acidbase balance

Question 96

A critically ill patient has arterial blood gas results of pH 7.35, PaCO2 55 mm Hg, and HCO3 28 mEq/L. How does the nurse interpret these results?

A) Respiratory acidosis

B) Metabolic alkalosis

C) Partially compensated metabolic alkalosis

D) Fully compensated respiratory acidosis

Question 97

A patient who is critically ill is attached to a saturation of mixed venous oxygen monitor (SvO2) and has an SvO2 value that is trending downward and is currently below normal at 55%. What clinical abnormality should the nurse suspect?

A) Increased cardiac output

B) Fever and shivering

C) Fluid volume overload

D) Oversedation

Question 98

The nurse is evaluating the chest radiograph of a critically ill patient and notices that the patients trachea has shifted to the left of midline. What additional finding would confirm the presence of a pneumothorax?

A) Absent or diminished breath sounds on the right

B) Lung fields generally white on chest radiograph

C) Lung fields dull to percussion on the right

D) Blunting of costophrenic angles on chest radiograph