ABGs
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
ANS: B Respir alkalosis
Rationale: 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.
PTS: 1 REF: p. 255
A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem?
A. Pneumoconiosis
B. Pleural effusion
C. Acute respiratory failure
D. Pneumonia
ANS: C Acute respir failure
Rationale: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.
PTS: 1 REF: p. 556
A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for?
A. Maintaining positive chest-wall pressure
B. Monitoring pleural fluid osmolarity
C. Providing positive intrathoracic pressure
D. Removing excess air and fluid
ANS: D removing excess air and fluid
Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.
PTS: 1 REF: p. 596
The nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess?
A. Fluid intake for the last 24 hours
B. Arterial blood gas (ABG) levels
C. Prior outcomes of weaning
D. Electrocardiogram (ECG) results
ANS: B ABGs
Rationale: Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?
A. Early ambulation
B. Increased dietary intake of protein
C. Maintaining the client in a supine position
D. Administering aspirin with warfarin
ANS: A Early ambulation
Rationale: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.
PTS: 1 REF: p. 535
The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of which condition?
A. Pneumothorax
B. Cardiac ischemia
C. Acute bronchitis
D. Aspiration
ANS: A Pneumothorax
Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, and aspiration.
A 70 year old male client is 48 hours post operative for a knee replacement and is exhibiting dyspnea, and restlessness. The nurse auscultates his lungs and hears diminished lower lobe sounds. A chest x-ray and Arterial blood gases are ordered. His results come back pH 7.29, PaCO2 48, HCO3 25. Which of the following is occurring?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A pH shows acidosis, the PaCO2 is high and acidotic, and the HCO3 is normal. This client is in respiratory acidosis.
A client who was involved in a workplace accident sustained a penetrating wound of the chest that led to acute respiratory failure. Which goal of treatment should the care team prioritize when planning this client's care?
A. Facilitation of long-term intubation
B. Restoration of adequate gas exchange
C. Attainment of effective coping
D. Self-management of oxygen therapy
ANS: B restoration of adequate gas exchange
Rationale: The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated
While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. Which conclusion should the nurse reach?
A. The system is functioning normally.
B. The client has a pneumothorax.
C. The system has an air leak.
D. The chest tube is obstructed
ANS: C system has an air leak
Rationale: The water-seal chamber of a wet chest drainage system has a one-way valve or water seal that prevents air from moving back into the chest when the client inhales. There is an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak, which requires immediate assessment and intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
Which of the following interventions are critical in preventing VAP Ventilator-associated pneumonia? Select all that apply
a. Perform daily sedation vacations and assess readiness to extubate
b. Elevate the HOB 30- 45 degrees
c. Ensure good hand hygiene prior to suctioning the client
d. Perform daily oral care
E. administer prophylactic antibiotics
A,B,C,D
a.Perform daily sedation vacations and assess readiness to extubate
b. Elevate the HOB 30- 45 degrees
c. Ensure good hand hygiene prior to suctioning the client
d. Perform daily oral care
The nurse is educating a client recovering from a pulmonary embolism about prevention of future venous thrombosis after discharge. What should the nurse include in the teaching?
A. Elevate your legs in bed by placing a pillow behind your knees.
B. Reduce your fluid intake to 1500 mL a day.
C. Do not sit with your legs crossed while working at your desk.
D. Apply ice packs to legs when you feel soreness or pain.
ans: C
Rationale: Preventing thrombus formation is an important part of PE prevention. Clients should elevate the legs but not place anything behind the knees, should not sit with legs crossed. If the client has calf pain they should be evaluated for DVT and not place ice packs on the area. Hinkle & Cheever, p. 617, Abrams, 153.
While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often?
A. Every 2 hours when the client is awake
B. When adventitious breath sounds are auscultated
C. When there is a need to prevent the client from coughing
D. When the nurse needs to stimulate the cough reflex
ANS: B adventitious breath sounds
Rationale: It is usually necessary to suction the client's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present.
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
ANS: A respiratory acidosis
Rationale: 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.
PTS: 1 REF: p. 262
A firefighter was trapped in a fire and is admitted to the intensive care unit for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of acute respiratory distress syndrome (ARDS) and is intubated. Which other supportive measure should be initiated in this client?
A. Psychological counseling
B. Nutritional support
C. High-protein oral diet
D. Occupational therapy
ANS: B Nutritional support
Rationale: Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS.
PTS: 1 REF: p. 572
The nurse is caring for a client with a closed drain chest tube. Which assessment finding requires immediate intervention? Select all that apply.
A. Chest tube becomes dislodged from patient’s chest
B. Patient develops sudden onset of dyspnea
C. Chest tube drainage changes from serous to sanguinous
D. Chest tube drainage system is below the patient’s chest
ans: A, B, C
A. Chest tube becomes dislodged from patient’s chest
B. Patient develops sudden onset of dyspnea
C. Chest tube drainage changes from serous to sanguinous
Rationale: It is important to maintain the integrity of the chest tube system by positioning the drainage system below the level of the chest. Chest tube dislodgment requires immediate assessment of lung sounds, physician notification, chest xray, and possible chest tube reinsertion. Sudden onset of dyspnea requires immediate assessment of lung sounds, RR pattern, assessment of chest tube patency, physician notification, possible chest xray, as patient might have increased pneumothorax, bleeding, fluid overload, or chest tube malfunction. Chest tube drainage that changes from serous to sanguinous indicates acute bleeding. Hinkle & Cheever, p. 541. Module 3,
The provider orders adding positive end-respiratory pressure (PEEP) of 10 cm H2O for a client with ARDS on mechanical ventilation. What assessment data would be the best indicator of the need for PEEP?
A. ejection fraction of 30%
b. Respir rate 20
c. PaO2 50 mm Hg
d. PaCo2 50 mm Hg
c.
PEEP delivers positive pressure during expiration to prevent alveolar collapse, improve ventilation-perfusion and is used for hypoxemia resistant to O2 therapy
A client with a pulmonary embolism is started on heparin intravenous (IV) infusion. To promote the safety, the nurse knows that which of the following should be readily available?
A. Protamine sulfate
B. Vitamin K
C. Tracheostomy tray
D. Calcium gluconate
ans: A Protamine sulfate
Rationale: Heparin is an anticoagulant that increases the risk of bleeding. Protamine sulfate should be available when a client is on heparin as a reversal agent if the aPTT gets too high. Abrams, p. 167 Module 2, Outcome 4 possible: 3
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.
ANS: B the kidneys excrete hydrogen ions and conserve bicarb ions to help restore balance
Rationale: 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).
PTS: 1 REF: p. 259
A client on a acute care unit has the following arterial blood gases: pH 7.32, PaCoo2 60 mm Hg, HCO3 22 meq/L, and Pao2 78 mm Hg. The client is irritable and has blurred vision. What is the priority nursing diagnosis for this client?
A. risk for infection
B. Deficient fluid volume
c. impaired gas exchange
D. decreased cardiac output
Answer C impaired gas exchange
The ABG shows respir acidosis and retained Co2