Test bank Exam 3: Black 8 Lewis 7 Igna 5 Igna 7 Lewis 8 Linton 5 Jarvis 6 Black 7 Dewit Igna 6 Javis 7 Linton 4 Phipps

Black 8 Lewis 7 Igna 5 Igna 7 Lewis 8 Linton 5 Jarvis 6 Black 7 Dewit Igna 6 Javis 7 Linton 4 Phipps Black: 8 Chapter 13 Acid base balance 1.When an individual’s serum pH begins to fall below 7.35, the mechanism that responds instantaneously to return the serum pH to normal level is a. ammonia gas combining with H+. b. excretion of acid by the lungs. c. plasma bicarbonate buffering the acid. d. secretion of hydrogen ions (H+) by the kidneys. ANS: C Blood buffers constitute the body’s first line of defense against acid-base imbalance. 2.A client in diabetic ketoacidosis has an elevated serum potassium ion (K +) level. The nurse explains to the client that this is caused by a. bicarbonate loss in the urine instead of K+ loss. b. binding of H+ to blood proteins. c. increased reabsorption of K+ in the distal tubule of the nephron. d. secretion by the kidneys of H+ and retention of K+. ANS: D In cases of serum H+ excess, more H+ is secreted by renal tubular cells, whereas K+ is retained, promoting hyperkalemia. Hyperkalemia also occurs because H+ and K+ exchange places in an attempt to maintain electroneutrality, with more H+ entering cells and more K+ leaving cells. 3. The nurse teaching a 32-year-old man with renal failure about the pathophysiologic mechanism of acid-base balance recognizes that the instructions have been understood when the client says a. “Acidic foods must be eliminated from my diet.” b. “I lose too much acid through my kidneys.” c. “My breathing increases to correct imbalances.” d. “My urine output will increase when my pH falls.” ANS: C When kidney disease impairs excretion of fixed acids, the respiratory system can increase ventilation to “blow off” excess acid as carbon dioxide. 4. The nurse explains to a concerned family member of a client who has developed respiratory acidosis that the kidneys a. achieve optimal compensation immediately. b. are unable to compensate. c. can achieve optimal compensation in about 3 days. d. will compensate within 24 hours. ANS: C The lungs or kidneys alter actual amounts of acid and base, but regulation by these systems is not instantaneous. The kidneys may require up to 72 hours to achieve optimal compensation. 5. In an assessment of current clients, the nurse recognizes that the client most likely to develop respiratory acidosis has a. chronic obstructive pulmonary disease. b. hypokalemia. c. salicylate overdose. d. pulmonary fibrosis. ANS: A Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Pulmonary fibrosis would be a much less common cause. Salicylate overdose could lead to metabolic acidosis, and hypokalemia could produce metabolic alkalosis. 6. The nurse is caring for a client who has developed metabolic acidosis and has an anion gap of 12 mEq/L. The nurse informs a family member that this finding indicates that the client’s acidosis is caused by a. accelerated lipid metabolism. b. an increase of fixed acid. c. increases in carbonic acid. d. loss of bicarbonate. ANS: D When acidosis is the result of the addition of acid, as in lactic acidosis, bicarbonate is consumed (but not lost to the body) in buffering most of the acid load. Unmeasured anions increase in number to maintain electroneutrality, thus increasing the anion gap. But in an acidosis where the anion gap remains normal (12 + 4 mEq/L), the acidosis is caused by a loss of base. Non–anion gap acidosis is also called hyperchloremic metabolic acidosis. 7. A client is admitted to the hospital with severe vomiting and is diagnosed with metabolic alkalosis. The nurse anticipates that the laboratory value that would support this diagnosis is a. arterial carbon dioxide tension (PaCO2) of 30 mm Hg.Q b. arterial pH of 7.30. c. serum calcium level of 9.0 mEq/L. d. serum potassium level of 3.0 mEq/L. ANS: D In metabolic alkalosis, hypokalemia results from fluid shifts or intestinal losses because its concentration as a cation is affected by the state of hydrogen ions. 8. The nurse assesses that the client admitted in respiratory acidosis has compensated when the arterial blood gas (ABG) readings are a. carbon dioxide level of 50 mm Hg and bicarbonate level of 30 mEq/L. b. carbon dioxide level of 50 mm Hg and bicarbonate level of 20 mEq/L. c. carbon dioxide level of 30 mm Hg and bicarbonate level of 30 mEq/L. d. carbon dioxide level of 30 mm Hg and bicarbonate level of 24 mEq/L. ANS: A If compensation is present, carbon dioxide and bicarbonate are abnormal (or nearly so) in opposite directions (e.g., one is acidotic and the other alkalotic). 9. For a 34-year-old client in renal failure who develops acidosis, the nurse would assess for a. drowsiness. b. hypoventilation. c. muscle hyperactivity. d. paresthesias. ANS: A Metabolic acidosis may be accompanied by compensatory hyperventilation and other manifestations of acidemia, such as lethargy, stupor, and hypotension. 10. To prevent error in sampling arterial blood gases (ABGs), the nurse will a. place the sample immediately in ice water. b. shake the sample to mix in heparin. c. transfer the sample from syringe to air-tight glass test tube. d. use a large beveled needle to withdraw the sample. ANS: A The sample should be placed in ice water immediately to prevent the effects of metabolism of white blood cells. 11. The nurse performs Allen’s test before obtaining an ABG specimen to determine a. if an allergy to heparin is present. b. if ulnar circulation is adequate. c. the patency of the radial artery. d. the presence of neuromuscular weakness. ANS: B Before radial puncture to obtain ABG specimens, Allen’s test should be performed to ascertain adequate ulnar circulation. Failure to assess ulnar circulation could result in ischemic injury to the client’s hand. 12. A client is brought to the emergency department in cardiac arrest. The nurse is aware that the associated acid-base imbalance that will require treatment is a. both respiratory and metabolic acidosis. b. both respiratory and metabolic alkalosis. c. d. respiratory acidosis. respiratory alkalosis. ANS: A In cardiac arrest, lactic acid quickly accumulates as a result of anaerobic metabolism. Carbonic acid is elevated as a result of respiratory arrest. 13. Receiving a client’s ABG report with pH of 7.40, PaCO 2 of 55 mm Hg, and bicarbonate level of 20 mEq/L, the nurse interprets these values to indicate a. erroneous blood gas data. b. metabolic alkalosis. c. mixed acid-base disorder. d. respiratory alkalosis. ANS: A The nurse should suspect sampling error or transcription error when the reported values lack internal consistency or external congruity. Internal consistency means that the values make sense when considered as a whole. External congruity means that the ABG findings are consistent with other laboratory data and with clinical assessment findings. In this case the PaCO2 is high, indicating an acidotic state. The pH is within normal range, which would indicate compensation, except the bicarbonate level is actually low, showing that no compensation is occurring to maintain normal pH in the presence of a high PaCO 2. This would lead the nurse to conclude that the ABG results are in error. 14. A client has a blood pH of 7.30 and is being treated with an infusion of sodium bicarbonate. The nurse should assess this client for a possible delayed reaction of increasing levels of which component in the blood? a. Bicarbonate b. Calcium c. Carbon dioxide d. Glucose ANS: C In acidosis, intravenous administration of sodium bicarbonate may have an immediate beneficial effect on pH. Eventually, however, blood levels of CO2 rise because HCO3 fuels the hydrolysis reaction in reverse. 15. The nurse caring for a trauma victim who has received massive transfusions of whole blood is diligent in assessment for metabolic alkalosis because a. multiple transfusions of whole blood cause a decrease in serum potassium level. b. the anticoagulant in the blood is metabolized to bicarbonate. c. transfused blood is less stable, releasing bicarbonate from the blood cells. d. whole blood utilizes bicarbonate as a preservative. ANS: D The citrate anticoagulant used for storage of blood is metabolized to bicarbonate. 16. The nurse is assigned to a client with insulin-dependent diabetes who was brought to the emergency department because of shortness of breath and confusion. On admission, the client’s blood glucose level is 720 mg/ml, and ABG values are pH of 7.28, PaCO2 of 35 mm Hg, and bicarbonate level of 15 mEq/L. The nurse interprets these readings as indicating a. compensated metabolic acidosis. b. compensated respiratory acidosis. c. uncompensated metabolic acidosis. d. uncompensated respiratory acidosis. ANS: C Diabetic ketoacidosis is one etiology of metabolic acidosis. The low pH represents an uncompensated state. The normal PaCO2 backs up the nurse’s assessment that the respiratory system has not yet started compensating. 17. A client with a diagnosis of chronic renal failure has pH of 7.35, PaCO 2 of 29 mm Hg, and bicarbonate level of 16 mEq/L. The nurse interprets these ABG results as a. compensated metabolic acidosis. b. compensated respiratory acidosis. c. uncompensated metabolic acidosis. d. uncompensated respiratory acidosis. ANS: A Renal failure is one etiology of metabolic acidosis. Compensation is present when PaCO 2 and bicarbonate values are abnormal (or nearly so) in opposite directions (e.g., one is acidotic and the other alkalotic), and when the pH is in the normal range. 18. The nurse is caring for an 80-year-old client admitted to the hospital with pneumonia and who is becoming progressively more confused. Her vital signs are as follows: T, 101° F; P, 112 beats/min; R, 28 breaths/min; BP, 100/70 mm Hg. ABG results are pH 7.50, PaCO2 25 mm Hg, and bicarbonate level 18 mEq/L. The nurse interprets these findings to indicate a. metabolic acidosis secondary to fever. b. metabolic alkalosis secondary to bicarbonate excess. c. respiratory acidosis secondary to anxiety. d. respiratory alkalosis secondary to hypoxemia. ANS: D Pneumonia is one cause of respiratory alkalosis, because the respiratory rate increases to compensate for hypoxemia, and excess “blowing off” of CO2 occurs. 19. The nurse caring for a client who experienced cardiopulmonary arrest and has a mixed respiratory/metabolic acidosis explains to a concerned family member that the mechanical ventilator can eliminate a. carbonic acid. b. lactic acid. c. phosphoric acid. d. sulfuric acid. ANS: A Carbonic acid in the blood can be transformed into hydrogen ions and carbon dioxide, which can be eliminated through the lungs. The other acids are fixed acids that must be excreted in the urine. 1. Age-related physiologic changes the nurse would consider when planning care for an elderly client admitted with an acid-base abnormality include (Select all that apply) a. decreased pulmonary and renal function limit the ability to compensate. b. hypermetabolism predisposes the elderly to metabolic acidosis. c. hypoventilation can easily cause respiratory acidosis in the elderly. d. renal perfusion is diminished because of decreased cardiac output. e. there is decreased alveolar surface area for gas exchange. ANS: A, C, D, E Many age-related physiologic changes limit the client’s ability to compensate for acid-base disturbances, including options a, c, d, and e above, plus the fact that the elderly take more medications that can contribute to hypokalemia and metabolic alkalosis. Aldosterone is also less effective in older persons, as is ammonia buffering. The elderly are not hypermetabolic. Chapter 63: Management of Clients with Acute Pulmonary Disorders 1. In the nursing care of a client recently intubated and placed on mechanical ventilation, the nursing action that would take highest priority is a. assessing for pedal pulses regularly. b. monitoring blood pressure frequently. c. monitoring temperature every 4 hours. d. turning the client every 2 hours. ANS: B The lowered cardiac output will be reflected in the hypotension that clients typically exhibit immediately after being placed on mechanical ventilation. It is imperative that blood pressure be monitored closely. 2. A client who was extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88 beats/min, respirations 18 breaths/min, blood pressure mm Hg, and PaCO2 45 mm Hg. Current vital signs include pulse 104 beats/min, respirations 26 breaths/min, blood pressure mm Hg. The nurse would a. administer a nebulized bronchodilator. b. assist with reintubation. c. obtain a complete blood count (CBC). d. prepare the client for a tracheostomy. mm Hg, and PaCO2 62 ANS: B The nurse should assess the client for indications of respiratory distress and hypoxemia, as evidenced by restlessness, irritability, tachycardia, tachypnea, and decreased PaO 2 or increased PaCO2. If these manifestations are noted, the nurse should notify the physician and prepare for reintubation. 3. The nurse monitoring a client with adult respiratory distress syndrome (ARDS) would closely assess for a. atelectasis. b. cor pulmonale. c. d. pneumonia. pulmonary edema. ANS: D The hallmark of ARDS is increased permeability of the pulmonary endothelium and alveolar epithelium, with resultant movement of fluid into the interstitial and alveolar spaces. This leads to the development of pulmonary edema, which decreases lung compliance and impairs oxygen transport. 4. A client admitted to the emergency department (ED) with severe chest injuries and significant hypovolemia caused by hemorrhage would be transfused to replace blood loss initially with a. albumin. b. dextrose 5% in normal saline. c. type AB-negative blood. d. type O-negative blood. ANS: D A chest-injured client may require large quantities of blood replacement. Until the results of typing and crossmatching are available, the client is given O-negative blood. 5. When a client is admitted to the ED with tension pneumothorax and mediastinal shift following an automobile accident, the nurse would know that the client would exhibit a. a sucking chest wound. b. bradycardia. c. mediastinal flutter. d. severe hypotension. ANS: D Mediastinal shift may cause (a) compression of the lung in the direction of the shift and (b) compression, traction, torsion, or kinking of the great vessels; thus blood return to the heart is dangerously impaired. The latter causes a subsequent decrease in cardiac output and blood pressure. 6. The nurse would explain that emergency treatment of a tension pneumothorax requires a. a small stab wound with a skin blade made into the pleural space. b. covering the chest wall wound with gauze. c. immediate tracheostomy. d. insertion of an 18-gauge needle into the pleural space. ANS: D The immediate intervention is to convert tension pneumothorax into open pneumothorax (a less serious disorder). If a delay is anticipated (with chest tube insertion), a 14- to 18-gauge needle is inserted into the pleural space of the affected side at the level of the second intercostal space at the midclavicular line. 7. When a client is admitted to the ED with a sucking chest wound, the nurse initially would a. cover the wound with whatever is available. b. leave the wound open. c. notify the physician. d. obtain a sterile gauze petroleum dressing to cover the wound. ANS: A When an open sucking chest wound is detected, emergency intervention includes immediately covering the wound securely with anything available. The nurse should not waste time looking for a sterile gauze petroleum dressing if it is not immediately available. 8. After dressing a sucking chest wound, the nurse notes that the client is developing severe dyspnea, tachypnea, cyanosis, tachycardia, and asymmetrical chest movements. The nurse would a. check the chest dressing for any air leakage. b. insert an 18-gauge needle into the pleural space. c. notify the physician. d. remove the chest dressing. ANS: D If a tension pneumothorax appears to be developing after the wound is sealed, the nurse should immediately unplug the seal to allow the air to escape. 9. When a client developed a hemothorax, the physician inserted a chest catheter connected to a drainage system. In the first 2 hours, 900 ml of blood drainage was collected. The nurse would a. clamp the tubing. b. continue observation of the drainage. c. monitor the client’s vital signs. d. report this to the physician immediately. ANS: D Large amounts of drainage (200 ml/hr or more) should be reported the physician immediately. 10. Once a near-drowning victim is stabilized, the nurse would continue to assess the client for a. bronchospasm. b. dyspnea. c. electrolyte imbalances. d. shock. ANS: B Clients are at high risk for pulmonary edema even several hours after a near-drowning incident. 11. The nurse would explain that the use of positive end-expiratory pressure (PEEP) assists the client on mechanical ventilation by a. gradually increasing the amount of oxygen delivered. b. increasing the amount of expired carbon dioxide. c. keeping the alveoli open. d. using a pressure of 30 cm H2O. ANS: C PEEP keeps the alveoli open to offer more ventilation surface by using pressures of 5 to 20 cm H 2O. 12. As part of the immediate care plan for a client with pulmonary edema and a nursing diagnosis of Impaired Gas Exchange, the nurse would a. administer oxygen as ordered using a high-flow rebreather bag. b. c. d. bring a tracheostomy set to the bedside. monitor vital signs every 30 to 45 minutes until stable. position the client’s legs above heart level. ANS: A The nurse should monitor vital signs every 15 minutes initially until the client is stable and administer oxygen as ordered using a high-flow rebreather bag to maintain oxygenation (oxygen saturation above 90%). Mechanical ventilation and intubation equipment should be nearby. To reduce preload, the client should be positioned with the legs dependent. Raising edematous legs increases venous return and will stress the overtaxed left ventricle. 13. A client with respiratory failure was intubated with an oral endotracheal (ET) tube 2 hours ago. Suspecting that the tube has changed position slightly since insertion, the nurse would assess the a. results of the chest x-ray film taken 2 hours earlier. b. current oxygen saturation readings. c. status of the client’s breath sounds. d. position of the numbers on the ET tube at the lip line. ANS: D The nurse records in the nursing notes and on the respiratory flow sheet the point at which the ET tube meets the lips or nostrils by using the numbers listed on the tube’s side. If the tube slips, its correct position can be quickly established. Then the nurse should listen to lung sounds. 14. A client who sustained a head injury is intubated and receiving volume-cycled mechanical ventilation via the controlled mechanical ventilation (CMV) mode. The nurse would explain that this means a. a preset amount of pressure stays in the client’s lungs at the end of exhalation. b. spontaneous inspiratory effort triggers the ventilator to deliver a preset tidal volume. c. the client’s own breaths can become “stacked” with the ventilator breaths. d. the ventilator delivers the preset volume regardless of the client’s efforts. ANS: D In the CMV mode the volume-cycled ventilator delivers a preset tidal volume. No allowance is made for spontaneous breaths. Because the ventilator is not responsive to the client’s efforts, the CMV mode can lead to agitation and asynchrony. 15. A client who underwent surgery is intubated and receiving mechanical ventilation. The client is receiving a neuromuscular blocking agent to stop spontaneous breathing that is not in synchrony with the ventilator. The appropriate approach by the nurse to the client’s postoperative pain control would be a. a sedative should be given with an anxiolytic and the neuromuscular blocker to control pain. b. an analgesic is needed specifically for pain contr...