Adult Health lll Exam 1 Questions with Verified Answers [2022/2023]
Adult Health lll Exam 1 Answers
1. The nurse should interpret the arterial blood
... [Show More] gas results shown below as which of the following?
pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L
a. respiratory alkalosis
b. metabolic acidosis
c. metabolic alkalosis
d. respiratory acidosis
Feedback: The ABGs shown indicate the pH is high which would mean alkalosis. The PaCO2 is low
which is the opposite of the pH and indicates that the respiratory system is the primary problem. The
HCO3 is within normal levels. Remember the acronym ROME when interpreting ABGs.Lewis 2017, pgs
290-291abcK
2. The nurse is caring for a client who is receiving prescribed intravenous (IV) fluids at 50 ml/hr,
has voided 300 ml in 24-hours and reports having a headache. The nurse notes the client's
laboratory results show a low urine specific gravity level. Which of the following actions should
the nurse take?
a. Encourage the client to increase their fluid intake.
b. Decrease the intravenous fluids.
c. Administer prescribed antibiotics.
d. Assist the client to ambulate to increase their metabolic rate.
Feedback: Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than
400 mL/d of urine) is the most common clinical situation seen in acute renal failure along with a low
urine specific gravity; anuria (less than 50 mL/d of urine) and normal urine output are not as common. In
acute renal failure you want to encourage the client to increase their fluid intake to prevent dehydration.
Administering antibiotics will not increase the client's decreased urine output. Decreasing IV fluids will
be putting the client at risk for dehydration. Increasing the metabolic rate will not assist the client in their
urine output deficit. Lewis 2017, pgs. 1071-1072abkd
3. The plan of care for a client with a low potassium level includes providing information about the
effects of medications and the dietary intake of foods high in potassium. Which of the following
information should the nurse use to evaluate if the outcome for the plan was met?
a. laboratory data
b. physical assessment
c. health history
d. client statements
Feedback: The interventions are aimed at increasing the potassium level of the client, and achievement
would be measured by evaluating laboratory data. Potassium levels cannot be measured by physical
assessment, health history information, or client statements. Lewis 2017, pgs. 282-283
4. The nurse caring for a client experiencing acute hypoxemic respiratory failure due to V/Q
mismatch is evaluating the client’s plan of care. Which of the following interventions would be
appropriate for the client’s care plan?
a. Initiate 24% to 32% oxygen via face mask.
b. Provide high flow supplemental oxygen via nasal cannula.
c. Provide oxygen via noninvasive positive pressure ventilation (NIPPV).
d. Initiate invasive positive pressure ventilation (PPV) via endotracheal tube for SaO2 below 90%.Feedback: The nurse should understand that acute hypoxemic respiratory failure due to V/Q mismatch
requires low levels of oxygen either via nasal cannula or using a face mask at 24% to 32% oxygen. This
helps improve the PaO2 and SaO2 levels. Without knowing the client’s baseline SaO2 an intervention to
initiate PPV vie ET tube for SaO2 would be inappropriate. NIPPV is typically the treatment of choice for
hypoxemia secondary to an intrapulmonary shunt, not V/Q mismatch.Lewis 2017, pgs. 1615-1616
5. The nurse is caring for a client with right sided pneumonia (PN) and helps position the client in
the left Sims position. The nurse should evaluate the client’s response to the position by doing
which of the following?
a. Compare the client’s PaO2 level with the previous level.
b. Assessing the client’s pain level.
c. Ask the client to perform coughing and deep breathing.
d. Compare the client’s pH and HCO3 levels with the baseline levels.
Feedback: Clients with unilateral lung disease should be positioned with the healthy lung in a dependent
position. This helps to mobilize the secretions which makes it easier to expectorate. The client’s PaO2
level compared to the previous level would give the nurse a good indication if the client’s ventilation has
increased. Lewis 2017, pgs. 1610-1611k, 1624-1625k, acd by omission
6. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is
mechanically ventilated with positive end-expiratory pressure (PEEP). Which of the following
should alert the nurse that the client is having complications from PEEP? Select all that apply.
a. tachycardia
b. hypopnea
c. decreased urine output
d. diminished lung sounds
e. hypertension
Feedback: PEEP is indicated in clients with ARDS. PEEP provides positive pressure at the end of
expiration to keep the alveoli open. This positive pressure can increase the intrathoracic pressure. When
intrathoracic pressure increases, the client will have a decrease in preload, which can decrease cardiac
output. When there is a decrease in cardiac output, the client can have tachycardia, hypotension, and
decreased perfusion to the kidneys. With increased intrathoracic pressure, barotrauma or pneumothorax
can occur. A client on mechanical ventilation should have equal and bilateral breath sounds, diminished
breath sounds may indicate a pneumothorax.Lewis 2017, pg. 1577Kbe
7. The nurse received report from the previous shift for a client who was intubated for acute
respiratory failure (ARF) less than one hour ago. Which of the following test results would be a
priority for the nurse to follow-up?
a. end-tidal CO2 (ETCO2)
b. complete blood count (CBC)
c. electrocardiogram (ECG)
d. mixed venous O2 saturation (SvO2)
Feedback: After a client is intubated the ETCO2 should be evaluated because this confirms proper tube
placement within the airway immediately after intubation. A CBC, ECG and SvO2 are also done after
intubation but would not be a priority over correct tube placement.Lewis 2017, p. 16148. A nurse is caring for a client in the emergency department (ED) who had a radiograph (x-ray) that
reveals rib fractures, and the client is diagnosed with a small flail chest injury. Which of the
following interventions should the nurse include in the client's plan of care?
a. suction the client's airway secretions
b. strict fluid intake and fluid replacement restriction
c. prepare the client for surgery
d. immediately sedate and intubate the client
Feedback: As with rib fracture, treatment of flail chest is usually supportive. Management includes
ventilatory support, clearing secretions from the lungs, and controlling pain. If only a small segment of
the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing,
and suctioning. Clients should have adequate fluid intake and replacement to mobilize secretions and
underlining pulmonary contusion. Intubation is required for severe flail chest injuries, and surgery is
required only in rare circumstances to stabilize the fail segment.Lewis 2017, pgs. 521-522kbcd, 1610k
9. The nurse is caring for a client who is receiving positive pressure ventilation and high levels of
PEEP via endotracheal intubation for acute respiratory distress syndrome (ARDS). The nurse
should contact respiratory therapy for which of the following findings?
a. The client’s FIO2 is at 65%.
b. The client’s PaO2 is at 75%.
c. The client’s blood pressure decreased from 110/68 mm/Hg to 89/60 mm/Hg in the last hour.
d. The client’s temperature increased from 98.8o F. to 100.1o F in the last hour.
Feedback: The nurse should contact respiratory therapy for a the decrease in blood pressure. Client’s
receiving high levels of PEEP can experience a reduction in blood return to the left side of the heart from
hyperinflation of the alveoli and compression of the pulmonary capillary bed which then causes dramatic
reduction in BP. The PEEP should be adjusted to correct the BP. The client’s temperature is unrelated to
respiratory therapy and the FIO2 and PaO2 are within expected levels. Lewis 2017, pg. 1624Kbc, d by
omission.
10. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The nurse
auscultates diminished breath sounds, which is a change from the client's baseline. The nurse
should monitor the client for which of the following potential complications?
a. dyspnea and hypoxemia
b. kyphosis and clubbing of the fingers
c. sepsis and pneumothorax
d. bradypnea and pursed lip breathing
Feedback: These changes in the airway require that the nurse monitor the client for dyspnea and
hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications.
Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea. Lewis 2017, p.
564k, acd by omission, 1610-1611k
11. The nurse is providing telephone triage and is speaking with the spouse of a client with asthma
who has a prescription for a short-acting inhaled beta-agonist to utilize as needed. The spouse
states, "My spouse’s personal best peak flow reading is 290 L/minute and today the reading is 220
L/minute." Which of the following would be an appropriate response by the nurse?
a. "This is a medical emergency take your spouse to the nearest emergency department (ED)."
b. "Your spouse should use the prescribed beta-agonist inhaler."
c. "A prescription for intravenous corticosteroids is most likely necessary."d. "Your spouse’s asthma is under good control."
Feedback: The peak flow measurement is in the mild zone (75-80%) of the client's personal best. The
asthma is not currently well-controlled and the client should start using the short-acting bronchodilator.
Lewis 2017, pgs. 543stem, 546abkd, 1610, 1618k
12. The nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure and has
the following arterial blood gas values: pH 6.88, HCO3 22 mEq/L, PCO2 60 mm Hg, PO2 50
mm Hg. Which of the following actions should the nurse take?
a. Apply a paper bag over the client's nose and mouth.
b. Apply the prescribed oxygen by mask or nasal cannula.
c. Administer 50 mL of prescribed sodium bicarbonate intravenously.
d. Obtain a prescription and administer 50 mL of 20% glucose and 20 units of regular insulin.
Feedback: The client has experienced a combination of metabolic and acute respiratory acidosis through
heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client
can breathe again, the fastest way to return to acid-base balance is to administer oxygen. Sodium
bicarbonate should not be administered because the client’s arterial bicarbonate level is normal. Applying
a paper bag over the client’s nose and mouth would worsen the acidosis. Glucose and regular insulin
would not be appropriate to administer to the client.Lewis 2017, p. 290, 1615k
13. The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of
the following actions by the nurse would help prevent ventilator associated pneumonia (VAP)?
a. practicing meticulous hand hygiene
b. maintaining the head of the client's bed elevated at least 10 degrees
c. suctioning of the client's oral cavity secretions every shift
d. ensuring the respiratory therapist changes the ventilator circuit tubing every 4 hours
Feedback: Because normal upper airway defenses are bypassed, clients who are intubated with
mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after
suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. The
client will need oral suctioning more frequently than every shift and at least 30-degree head of the bed
elevation. It is not necessary to change the ventilator circuit tubing every 4 hours. The more frequently the
circuit is broken, the greater the risk for pathogen entry. Lewis 2017, p. 1623
14. The nurse is caring for a client experiencing acute respiratory failure (ARF) from acute
bronchitis. Which of the following medication prescriptions should the nurse question?
a. methylprednisolone via nebulization
b. albuterol via nebulization
c. furosemide via IV
d. azithromycin via IV
Feedback: The nurse should question the methylprednisolone via nebulization. This is a corticosteroid
and when they are inhaled, they require 4 to 5 days for optimum therapeutic effects. This would not be
appropriate for a client experiencing ARF. The other medications and routes are appropriate for this client.
Lewis 2017, p. 1618abcK15. The nurse is assessing a client with end stage kidney disease (ESKD). The client's serum
laboratory results indicate hypocalcemia and hyperphosphatemia. Which of the following
findings should the nurse anticipate? Select all that apply.
a. Trousseau's sign
b. cardiac arrhythmia's
c. constipation
d. decreased clotting time
e. drowsiness and lethargy
f. fractures
Feedback: Hypocalcemia is a deficit that causes nerve fibers irritability and repetitive muscle spasms.
Signs and symptoms of hypocalcemia include cardia arrhythmias, diarrhea, increased clotting times,
anxiety and irritability. The calcium/phosphorus imbalance leads to brittle bones and pathologic
fractures. Lewis 2017, pgs. 284-258
16. The nurse is assessing a client who reports shortness of breath (SOB) and notes diminished breath
sounds in the right lower lobe. A chest radiograph (x-ray) reveals a large right pleural effusion
with significant atelectasis. The nurse should anticipate which of the following procedures to be
prescribed for this client?
a. thoracentesis
b. bronchoscopy
c. ventilation/perfusion (V/Q) scan
d. repeat chest radiograph (x-ray)
Feedback: Thoracentesis is an uncomplicated procedure done at the bedside for the removal of fluid or
air from the pleural space. It is used most often as a diagnostic measure; it may also be performed
therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would
necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest
radiograph is not indicated. Lewis 2017 pgs. 527-528stem and k, bcd by omission, 1610-1611c
17. The nurse provided discharge teaching for a client with mild chronic obstructive pulmonary
disease (COPD) about breathing exercises. Which of the following statements by the client would
indicate a correct understanding of the teaching?
a. "I should practice using diaphragmatic breathing in the sitting position."
b. "I will lie in the supine position to facilitate air entry when practicing deep breathing."
c. "I should use pursed lip breathing as a last resort."
d. "I will practice chest breathing."
Feedback: Inspiratory muscle training and breathing retraining may help improve breathing patterns in
clients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar
ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing
helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration
and should not only be used as a last resort. Diaphragmatic breathing, not chest breathing, increases lung
expansion. Supine positioning does not aid breathing. Lewis 2017, p. 568-569
18. The nurse is providing discharge instructions for a client who experienced respiratory acidosis
from severe chronic obstructive pulmonary disease (COPD). Which of the following information
would help prevent future episodes of respiratory acidosis?
a. “Using pursed-lip breathing can help slow your respiratory rate.”
b. “When you feel out of breath you should use diaphragmatic breathing.”c. “Paradoxic breathing should be used when you are exercising.”
d. “You should avoid using home oxygen when you are resting and sleeping.”
Feedback: The client should be taught to use pursed lip breathing to slow the respiratory rate and work of
breathing which will help prevent respiratory acidosis. Diaphragmatic breathing for clients with COPD
can actually increase the work of breathing and exacerbate dyspnea especially clients with severe COPD.
During paradoxic breathing the chest and abdomen move outward with exhalation and inward with
inspiration which is the opposite of how they should move. This movement during breathing does not
help a client with COPD decrease the work of breathing. Oxygen use should not be avoided. Client’s with
COPD who use long-term O2 have increased survival. Oxygen should be used during exercise and sleep
especially, and evaluated on an individual bases for necessity. Lewis 2017, pgs. 568-570akd, 288k, 1614b
19. The nurse is evaluating the appropriateness of a physician’s prescription for continuous positive
airway pressure (CPAP) with the delivery of oxygenation. The nurse should expect the
prescription to be for which of the following clients?
a. The client with muscular dystrophy who is experiencing symptoms of acute respiratory failure
(ARF).
b. The client who experienced near drowning with an SaO2 level of 89% and has crackles in all
lung fields.
c. The client diagnosed with pneumonia who requires 100% oxygen and refuses to have
endotracheal intubation.
d. The client in hypovolemic shock who is experiencing symptoms of acute respiratory distress
syndrome (ARDS).
Feedback: Continuous positive airway pressure (CPAP), a form of non-invasive positive pressure
ventilation (NIPPV), is used with oxygen therapy to reverse or prevent micro-atelectasis, allowing a
lower percentage of oxygen to be used. NIPPV is most useful in managing chronic respiratory failure in
clients requirements, who have excessive secretions of are hemodynamically unstable are not good
candidates for NIPPV. Lewis 1617abkd, 1610k
20. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) that is being
mechanically ventilated. Which of the following lab results would indicate to the nurse that the
mechanical ventilation is providing adequate gas exchange for the client?
a. increased CO2 and PaO2 levels
b. decreased CO2 level and increased PaO2
c. decreased Ph and PaO2 levels
d. decreased CO2 and PaO2 levels
Feedback: Adequate gas exchange during mechanical ventilation is measured by a decrease in CO2 and
increase in PaO2 levels. The levels in the distractors are incorrect and indicators that a client would need
to be mechanically ventilated because the gas exchange is inadequate. Lewis 2017, pgs. 1571abkd
21. A client with acute respiratory distress syndrome (ARDS) who is intubated and receiving
mechanical ventilation develops a right pneumothorax. The nurse should notify respiratory
therapy to take which of the following actions?
a. lower the positive end-expiratory pressure (PEEP)
b. increase the tidal volume and respiratory rate
c. decrease the fraction of inspired oxygen (FIO2)
d. perform endotracheal suctioning more frequentlyFeedback: Complications that can occur from mechanical ventilation includes barotrauma which can
lead to pneumothorax which requires the PEEP to be decreased. Suctioning the client is unrelated to
pneumothorax. Increasing the tidal volume and RR would only exacerbate the problem. Decreasing the
FIO2 would not assist in correcting the complication of pneumothorax. Lewis 2017, pgs. 1616, 1623
22. The nurse is evaluating the arterial blood gas (ABG) results for a client experiencing acute
respiratory distress syndrome who has received prone positioning. Which of the following would
indicate the prone positioning was successful?
a. PaO2 level changed from 60 mm Hg to 85 mm Hg
b. pH is 7.34 and PaCO2 is 33 mm Hg
c. HCO3 level changed from 25 mEq/L to 35 mEq/L
d. pH is 7.45 and HCO3 is 26
Feedback: The nurse should check the client’s PaO2 level for an increase to show that the client’s
perfusion/ventilation is better matched. The prone positioning allows for fluid filled alveoli that were in
the dependent area, when the client was supine, to drain to the anterior portion of the lungs, which
become the dependent lungs when in the prone position. This helps to improve ventilation of betterperfused lung areas. The changes in the HCO3 level indicate the HCO3 has increased which would not
indicate the position helped with ventilation. The other two distractors do not provide enough information
to know if there is an improvement. Lewis 2017, p. 290kbcd, 1624-1625k
23. The nurse is caring for a client who received long-term prescribed aminoglycoside antibiotic
therapy for an infection. The nurse notes the client's potassium level is 5.4 mEq/L and the client's
electrocardiogram (ECG) shows peaked T-waves. Which of the following actions should the
nurse take?
a. Notify the healthcare provider and request a prescription for polystyrene sulfonate.
b. Notify the healthcare provider and request a prescription for a hypotonic IV solution.
c. Encourage the client to increase intake of potassium rich foods.
d. Monitor skin turgor and presence of edema every shift.
Feedback: Hyperkalemia, a common complication of acute kidney injury, is life-threatening if immediate
action is not taken to reverse it. The administration of polystyrene sulfonate reduces serum potassium
levels. Increasing potassium will increase the problem of hyperkalemia. Giving a hypotonic solution is
treatment for hypernatremia not hyperkalemia.Lewis 2017, pgs. 280-282abkd
24. The nurse is reviewing the arterial blood gas (ABG) results for a client who was admitted with a
bowel obstruction and has nasogastric tube (NG) with continuous suction. Which of the
following ABGs would indicate to the nurse the client is experiencing a complication from the
NG tube?
a. pH = 7.47 PaCO2 = 30 HCO3 = 22
b. pH = 7.30 PaCO2 = 50 HCO3 =25
c. pH = 7.28 PaCO2 = 41 HCO3 = 19
d. pH = 7.50 PaCO2 = 40 HCO3 = 39
Feedback: Clients who have a prescription for continuous suction are at increased risk for metabolic
alkalosis indicated by pH =7.50 CO2 = 40 HCO3 = 39, due to a loss of hydrogen and chloride ions from
gastric fluids. Gastric fluids are acidic.
25. The nurse administered prescribed IV morphine to a client who was 18 hours postoperative and
reported feeling anxious and having incisional pain. The client’s respiratory rate was 25breaths/min, and the arterial blood gas (ABG) results were pH 7.50, PaO2 89 mm Hg, PaCO2 28
mm Hg, and HCO3 23 mEq/L. The nurse should expect which of the following changes in the
client’s condition? Select all that apply.
a. decreased pain
b. decreased respirations
c. decreased pH level
d. decreased HCO3 level
e. decreased PaCO2 level
Feedback: After receiving pain medication (morphine) the client should experience decreased pain,
respirations, pH level and an increase in the PaCO2 level. The HCO3 level is already within normal levels
and would not expect to change. The client is experiencing respiratory alkalosis. Lewis 2017, pgs 289-
291kdeVallerand 2017, pgs 866-870k
26. The nurse has attended a staff education conference about fluid balance. Which of the following
statements, if made by the nurse, would indicate a correct understanding of homeostatic
mechanisms in the body that regulate body fluid? Select all that apply.
a. "I will monitor urine output to measure the kidney's effect on fluid volume balance."
b. "Clients who have a lack of antidiuretic hormone (ADH) are at risk for fluid volume deficit
(FVD)."
c. "Thirst triggers a mechanism in the hypothalamus to maintain fluid balance."
d. "Clients with increased levels of aldosterone are at risk for fluid loss."
e. "The amount of fluid loss through exhalation has no impact on fluid balance."
Feedback: The adrenals act to regulate fluid balance with the use of aldosterone. Decreased blood
volume promotes increased aldosterone which results in sodium and water retention. Approximately 300
ml of water is lost daily through exhalation (insensible water loss). Low levels of antidiuretic hormone
(ADH) have an impact on fluid balance. The thirst center in the hypothalamus regulates oral intake by
sensing intracellular dehydration. The kidneys regulate extracellular fluid (ECF) volume by selective
retention and excretion of body fluids. Lewis 2017, pgs. 274-275
27. The nurse is assessing a client who experienced metabolic alkalosis from food poisoning and
received intermittent parenteral fluid therapy. Which of the following findings would indicate that
the fluid therapy was successful?
a. pH and HCO3 levels have decreased
b. pH and PaCO2 levels have increased
c. pH level has decreased and HCO3 level has increased
d. pH level has decreased and PaCO2 level has increased
Feedback: The client experiencing metabolic alkalosis would have high pH and HCO3 levels, so if the
IV fluids were successful the pH and HCO3 levels should have decreased. If the pH or HCO3 increased
the client’s metabolic alkalosis would be worsening. The PaCO2 would be normal or increased with
metabolic alkalosis, so if the fluids were successful the level should not increase more.Lewis 2017, pgs.
290-291, 288.
28. The nurse reviews the nursing care plan of a client with pneumonia and notes documentation of a
nursing diagnosis of Activity intolerance. The nurse should implement which of the following in
the client’s plan of care?
a. obtain vital signs and oxygen saturation periodically during activity
b. encourage deep, rapid breathing during activityc. maintain bedrest except for meals, assist client out of bed
d. schedule activities before giving prescribed respiratory medications or treatments
Feedback: The nurse monitors vital signs, including oxygen saturation, before, during, and after activity
to gauge client response. Activities should be planned after giving the client respiratory medications or
treatments to increase activity tolerance. The client should use pursed-lip and diaphragmatic breathing to
lower oxygen consumption during activity. Finally, the environment should be conducive to rest because
the client is easily fatigued. Lewis 2017, pgs. 506abkd
29. The nurse is evaluating the care plans for a group of assigned clients who have acute respiratory
failure with a new nursing diagnoses of ineffective airway clearance related to excessive
secretions. Which of the following clients requires immediate revision of the care plan?
a. The client receiving non-invasive positive pressure ventilation.
b. The client who cannot perform huff coughing.
c. The client taking in 1,200 to 1,500 L/day of oral fluids.
d. The client whose SaO2 decreased from 96% on 2 L nasal canula to 93%.
Feedback: The client receiving non-invasive positive pressure ventilation needs immediate revision of
the care plan because it is not appropriate for clients who have excessive secretions. The clients in the
distractors do not require immediate revisions, but they do require revisions. Huff coughing can help
clients expectorate secretions and if the client is unable to perform huff coughing there are other
therapeutic cough techniques that can be used. The client with excessive secretions should be able to take
in 2 to 3 L/day of oral fluids otherwise should receive IV hydration to help thin the secretions. An SaO2
decreasing from 96% to 93% is not an emergency unless the client had other signs of hypoxia. Lewis
2017, p. 1616-1617
30. The nurse is caring for a client with acute respiratory failure from an opioid overdose. Which of
the following findings would indicate the treatment goals were achieved? Select all that apply.
a. The client’s arterial blood gas (ABG) results show signs of compensation.
b. The client’s PaCO2 has returned to baseline.
c. The client denies having any pain.
d. The client’s SaO2 is 97% on room air.
e. The client has a respiratory rate of 20 with a regular rhythm.
Feedback: Acute respiratory failure from an opioid overdose causes central nervous system
abnormalities. The goals of treatment include independent maintenance of the airway, normal ABG values
or within the client’s baseline and returning to baseline or within normal limits of breathing patterns.
Metabolic compensation for an overdose is not likely to occur since it is an acute issue therefore the
kidneys do not have time to compensate for the respiratory failure. Absence of pain is not a goal of
treatment for respiratory overdose as the client would not be expected to have pain. Lewis 2017, pgs.
1615k, ac by omission, 1610stem, 1612k
31. The parents of a child with asthma ask the nurse how a prescribed inhaled beta-agonist works.
Which of the following would be the best response by the nurse?
a. "Beta agonists relax smooth muscles in the airway, which then dilate rapidly."
b. "Beta agonists increase airway inflammation and hyper-responsiveness."
c. "The medication is given to stop your child's wheezing."
d. "Beta agonists reduce mucosal edema in the airway, thereby increasing the diameter."Feedback: The action of a beta agonist is to relax smooth airway muscle, resulting in bronchodilation.
When inhaled, it exerts action directly on the airway. While it is true that albuterol may 'stop the
wheezing' this is not the best selection and does not answer the parent's question. Beta agonists do not
reduce edema or inflammation. Vallerand 2017, pgs. 120-121
32. The nurse is caring for a client who is postoperative lung surgery. The client has a shallow,
monotonous respiratory pattern and is reluctant to cough. The nurse should assess the client for
which of the following?
a. atelectasis
b. increased oxygen saturation
c. increased risk for aspiration
d. malnutrition
Feedback: The reluctance to cough is likely due to poor pain control. A shallow, monotonous respiratory
pattern places the client at an increased risk of developing atelectasis. The client would not be at increased
risk for increased oxygen saturation, aspiration, or malnutrition. Lewis 2017, pgs. 1621-1622k, acd by
omission, 334k
33. The nurse is caring for a group of assigned clients. The nurse should prepare to administer
prescribed bicarbonate intravenously to the client with which of the following clinical
manifestations?
a. pH 7.28, HCO3– 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea
b. pH 7.28, HCO3– 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg secondary to an acute asthma
attack
c. pH 7.30, HCO3– 30 mEq/L, PCO2 60 mm Hg, PO2 72 mm Hg secondary to chronic bronchitis
and emphysema
d. pH 7.31, HCO3– 20 mEq/L, PCO2 34 mm Hg, PO2 96 mm Hg secondary to a urinary tract
infection (UTI) and diabetes mellitus, type 2 (DM-2)
Feedback: The only client who has lower than normal bicarbonate levels is the client with diarrhea. This
deficit is most likely the result of an actual bicarbonate loss, and bicarbonate should be replaced to help
return this client’s acid-base balance to normal. Giving bicarbonate to any of the other clients listed would
be adding too much base and would risk the development of alkalosis. Lewis 2017, pgs. 290-291kbcd
34. The nurse is caring for a client in the emergency room who reports increased urination, and
appetite, headache and blurred vision. The client’s ABG results are; pH 7.30, PaCO2 35 mm/Hg,
and HCO3 19 mm/Hg. Which of the following would be the best action for the nurse to take?
a. Administer prescribed intravenous fluids and insulin.
b. Check the client’s vital signs and oxygen saturation level.
c. Assess the client for signs of infection.
d. Administer prescribed intravenous corticosteroids.
Feedback: The client is experiencing signs and symptoms of diabetic ketoacidosis which causes
metabolic acidosis; low pH level and HCO3 level. The nurse should administer IV fluids and insulin to
correct the increased blood sugar. The vital signs should be monitored, and it is possible the client could
have an infection, but those would not be the best actions by the nurse. A corticosteroid would only
increase the client’s blood sugar and would not be an appropriate action. Lewis 2017, pgs. 1142-
1143stem, 1144kb, cd by omission, 289stem and k.35. The nurse working in the emergency department (ED) reviews arterial blood gas (ABG) values
for a client diagnosed with respiratory failure and notes the client's pH 7.58, PaCO2 20, PaO2 75,
HCO3 28, and SaO2 92%. Which of the following interventions should be a priority for the
nurse?
a. preparing the client for endotracheal intubation and mechanical ventilation
b. contacting the client’s family to come sit with the client and explaining that the client's ABG's are
within normal limits (WNL)
c. immediately starting an infusion of dextrose 50% in water solution (D50W)
Feedback: This client is experiencing respiratory alkalosis related to respiratory failure. The pH level is
elevated in hyperventilation; the client’s hyperventilation will “blow off” more CO2, leading to lower
pCO2 levels. Decreased pCO2 is caused by hyperventilation. With rapid breathing SO2 can be increased
with deep or rapid breathing. Acute airway management is indicated to improve tissue oxygenation.
Airway support meets the client’s physiologic need for a clear airway. Spiritual support is a higher level
(self-actualization) on Maslow’s hierarchy. Providing IV management for circulatory support is a basic
physiologic need; however, airway management is priority. Lewis 2017, pgs. 288-290k, bcd by omission,
1614-1615k
36. The nurse in the emergency department (ED) is caring for a client who reports acute dyspnea,
pain and anxiety. The client’s blood pressure is 140/85 mm/Hg, pulse is 110 beats/minute and
SaO2 is 85%. ABG values are; pH 7.50, PaCO2 29 mm/Hg, and HCO3 24 mm/Hg. Which of the
following actions should the nurse take? Select all that apply.
a. administer oxygen therapy
b. encourage the client to breathe slowly
c. prepare the client for intravenous therapy to promote compensation
d. administer prescribed pain medication
e. obtain a medical history from the client to determine the cause of symptoms
Feedback: The client is experiencing respiratory alkalosis based on the ABG levels. The pH is high and
the PaCO2 is low. The nurse should administer oxygen, and pain medication and encourage the client to
slow the breathing because pain can cause respiratory alkalosis and hyperventilation increases the pH
levels. Obtaining as much of a medical history from the client as possible is key to treating the cause.
With respiratory alkalosis, compensation is typically not possible because the client requires aggressive
treatment of the hypoxemia. Lewis 2017 pgs. 288-289ck, stem, 1614-1615k
37. The nurse is developing the plan of care for a client with acute respiratory failure (ARF) that is
being mechanically ventilated. The nurse understands that suctioning can prevent which of the
following complications?
a. alveolar hypoventilation
b. dead space ventilation
c. Incorrect answer:
d. ventilation/perfusion mismatching
e. intrapulmonary shunting
Feedback: Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory
failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes
of hypoxemia are alveolar hypoventilation, ventilation/perfusion (V/Q) mismatching, and intrapulmonary
shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not
ventilated and can occur with mucous plugs, obstruction in the distal airway, pneumonia, atelectasis.
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