ABG Analysis Past Paper PDF

ABG ANALYSIS (PART 1) 1. Question George Kent is a 54-year-old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty communicating be...

ABG ANALYSIS (PART 1) 1. Question George Kent is a 54-year-old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Acidosis, Partially Compensated Correct Answer: B. Respiratory Acidosis, Partially Compensated The patient has respiratory acidosis (raised carbon dioxide) resulting from an acute exacerbation of chronic obstructive pulmonary disease, with partial compensation. 2. Question Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two-week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Acidosis, Partially, Compensated Correct Answer: D. Metabolic Acidosis, Partially, Compensated The student was diagnosed with diabetes mellitus. The results show that he has metabolic acidosis (low HCO3 -) with respiratory compensation (low CO2). 3. Question A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean? A. Respiratory Alkalosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated Correct Answer: A. Respiratory Alkalosis, Uncompensated The primary disorder is acute respiratory alkalosis (low CO2) due to the pain and anxiety causing her to hyperventilate. There has not been time for metabolic compensation. 4. Question Ricky’s grandmother has been suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown? A. Respiratory Alkalosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated Correct Answer: C. Metabolic Alkalosis, Uncompensated The primary disorder is uncompensated metabolic alkalosis (high HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for metabolic alkalosis. 5. Question Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client’s respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli. The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg, and HCO3 24 mEq/L. What does this mean? A. Respiratory Alkalosis, Partially Compensated B. Respiratory Acidosis, Uncompensated C. Metabolic Alkalosis, Partially Compensated D. Metabolic Acidosis, Uncompensated Correct Answer: B. Respiratory Acidosis, Uncompensated The results show that Mrs. Johansson has respiratory acidosis because of decreased pH and increased PaCO2 which means acidic in nature. Meanwhile, it is uncompensated because HCO3 is within the normal range. 6. Question Baby Angela was rushed to the Emergency Room following her mother’s complaint that the infant has been irritable, difficult to breastfeed, and has had diarrhea for the past 3 days. The infant’s respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg, and HCO3 19 mEq/L. What does this mean? A. Respiratory Alkalosis, Fully Compensated B. Metabolic Acidosis, Uncompensated C. Metabolic Acidosis, Fully Compensated D. Respiratory Acidosis, Uncompensated Correct Answer: C. Metabolic Acidosis, Fully Compensated Baby Angela has metabolic acidosis due to decreased HCO3 and slightly acidic pH. Her pH value is within the normal range which made the result fully compensated. 7. Question Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment? A. Metabolic Acidosis, Uncompensated B. Metabolic Alkalosis, Uncompensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated Correct Answer: B. Metabolic Alkalosis, Uncompensated The postoperative client’s ABG results show that he has metabolic alkalosis because of an increased pH and HCO3. It is uncompensated due to the normal PaCO2 which is within 35 to 45 mmHg. 8. Question Client Z is admitted to the hospital and is to undergo brain surgery. The client is very anxious and scared of the upcoming surgery. He begins to hyperventilate and becomes very dizzy. The client loses consciousness and the STAT ABGs reveal pH 7.61, PaCO2 22 mmHg, and HCO3 25 mEq/L. What is the ABG interpretation based on the findings? A. Metabolic Acidosis, Uncompensated B. Respiratory Alkalosis, Partially Compensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated Correct Answer: C. Respiratory Alkalosis, Uncompensated The results show that client Z has respiratory alkalosis since there is an increase in the pH value and a decrease in PaCO2 which are both basic. It is uncompensated due to the normal HCO3 which is within 22- 26 mEq/L. 9. Question Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. The mother of the child reports to the nurse on duty that she has witnessed slight tremors and behavioral changes in her child over the past four days. The attending physician orders routine ABGs following an assessment of the ABCs. The ABG results are pH 7.35, PaCO2 72 mmHg, and HCO3 38 mEq/L. What acid-base disorder is shown? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Fully Compensated C. Respiratory Alkalosis, Fully Compensated D. Metabolic Alkalosis, Partially Compensated Correct Answer: B. Respiratory Acidosis, Fully Compensated The patient has respiratory acidosis (raised carbon dioxide) resulting from asthma and respiratory distress syndrome, with compensation having normal pH value within 7.35to 7.45, increased PaCO2 which is acidic and increased HCO3 which is basic. 10. Question Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials “911” because Anne is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided? A. Metabolic Acidosis B. Metabolic Alkalosis C. Respiratory Acidosis D. Respiratory Alkalosis Correct Answer: C. Respiratory Acidosis One of the risk factors of having respiratory acidosis is hypoventilation which may be due to brain trauma, coma, and hypothyroidism or myxedema. Other risk factors include COPD, Respiratory conditions such as pneumothorax, pneumonia, and status asthmaticus. Drugs such as Morphine and MgSO4 toxicity are also risk factors of respiratory acidosis. 11. Question Dave, a 6-year-old boy, was rushed to the hospital following her mother’s complaint that her son has been vomiting, nauseated and has overall weakness. After a series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis Correct Answer: D. Metabolic Alkalosis Vomiting, hypokalemia, overdosage of NaHCO3 and NGT suctioning are considered risk factors of metabolic alkalosis.  12. Question An older person experiencing homelessness was admitted to the emergency department due to shortness of breath, fever, and a productive cough. Upon examination, crackles and wheezes are noted in the lower lobes; he appears to be tachycardic and has a bounding pulse. Measurement of arterial blood gas shows pH 7.2, PaCO2 66 mm Hg, HCO3 27 mmol/L, and PaO2 65 mm Hg. As a knowledgeable nurse, you know that the normal value for pH is: A. 7.20 B. 7.30 C. 7.40 D. 7.50. Correct Answer: C. 7.40. Normal blood pH must be maintained within a narrow range of 7.35-7.45 to ensure the proper functioning of metabolic processes and the delivery of the right amount of oxygen to tissues. Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45. 13. Question Liza’s mother is seen in the emergency department at a community hospital. She admits that her mother is taking many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F; apical pulse = 95; respiration = 32 and deep. Which primary acid-base imbalance is the client at risk for if medical attention is not provided? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis Correct Answer. C. Metabolic Acidosis Salicylate overdose causes a high anion gap metabolic acidosis in both children and adults. Adults commonly develop a mixed acid-base disorder as a respiratory alkalosis due to direct respiratory center stimulation occurs as well. This second disorder is uncommon in children. 14. Question A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 22 mm Hg, and HCO3 14 mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that the normal value for PaCO2 is: A. 22 mm Hg B. 36 mm Hg C. 48 mm Hg D. 50 mm Hg Correct Answer: B. 36 mm Hg The normal range for PaCO2 is from 35 to 45 mm Hg. 15. Question A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not provided? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis Correct Answer: B. Respiratory Alkalosis Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation is also known as overbreathing. When someone is hyperventilating, they tend to breathe very deeply or very rapidly. 16. Question An elderly client was admitted to hospital in a coma. Analysis of the arterial blood gave the following values: PCO2 16 mm Hg, HCO3- 5 mmol/L and pH 7.1. As a well-rounded nurse, you know that the normal value for HCO3 is: A. 20 mmol/L B. 24 mmol/L C. 29 mmol/L D. 31 mmol/L Correct Answer: B. 24 mmol/L The normal value for bicarbonate (HCO3) is 22-26 mmol/L or mEq/L. It may vary slightly among different laboratories. The given values show the common measurement range of results for these tests. Some laboratories use different measurements or may test different specimens. 17. Question In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis Correct Answer: D. Metabolic Alkalosis NGT suctioning, vomiting, hypokalemia and overdosage of NaHCO3 are considered risk factors of metabolic alkalosis. 18. Question A mountaineer attempts an assault on a high mountain in the Andes and reaches an altitude of 5000 meters (16,400 ft) above sea level. What will happen to his arterial PCO2 and pH? A. Both will be lower than normal. B. The pH will rise and PCO2 will fall. C. Both will be higher than normal due to physical exertion. D. The pH will fall and PCO2 will rise Correct Answer: B. The pH will rise and PCO2 will fall. The mountaineer will suffer from a respiratory alkalosis. The decline in the PO2 with altitude will stimulate breathing to offset the hypoxia. Carbon dioxide is driven from the blood faster than it is produced in the tissues so PCO2 falls and pH rises. 19. Question A young woman is found comatose, having taken an unknown number of sleeping pills an unknown time before. An arterial blood sample yields the following values: pH 6.90, HCO3- 13 meq/liter, and PaCO2 68 mmHg. This patient’s acid-base status is most accurately described as: A. Metabolic Acidosis B. Respiratory Acidosis C. Simultaneous Respiratory and Metabolic Acidosis D. Respiratory Acidosis with Complete Renal Compensation Correct Answer: C. Simultaneous Respiratory and Metabolic Acidosis Whenever the PCO2 and HCO3 are abnormal in opposite directions, ie, one above normal while the other is reduced, a mixed respiratory and metabolic acid-base disorder exists. When the PCO2 is elevated and the [HCO3-] reduced, respiratory acidosis and metabolic acidosis coexist. 20. Question A mother is admitted to the emergency department following complaints of fever and chills. The nurse on duty took her vital signs and noted the following: Temp = 100 °F; apical pulse = 95; respiration = 20 and deep. Measurement of arterial blood gas shows pH 7.37, PaO2 90 mm Hg, PaCO2 40 mm Hg, and HCO3 24 mmol/L. What is your assessment? A. Hyperthermia B. Hyperthermia and Respiratory Alkalosis C. Hypothermia D. Hypothermia and Respiratory Alkalosis Correct Answer: A. Hyperthermia An individual is considered to have hyperthermia if he or she has a temperature of >37.5 or 38.3 °C (99.5 or 100.9 °F). The measurement of arterial blood gases are normal. RESPIRATORY EXAM (PART 1) 1. Question Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to: A. Promote expectoration. B. Suppress the cough. C. Relax smooth muscles of the bronchial airway. D. Prevent infection. Correct Answer: C. Relax smooth muscles of the bronchial airway. Aminophylline is a bronchodilator that directly relaxes the smooth muscles of the bronchial airway. Theophylline causes non-selective inhibition of type III and type IV isoenzymes of phosphodiesterase, which leads to increased tissue cyclic adenosine monophosphate (cAMP) and cyclic 3?,5? guanosine monophosphate concentrations, resulting in smooth muscle relaxation in lungs and pulmonary vessels, diuresis, CNS and cardiac stimulation. Option A: Guaifenesin is an expectorant. It works by thinning and loosening mucus in the airways, clearing congestion, and making breathing easier. Mucolytics are drugs belonging to the class of mucoactive agents. They exert their effect on the mucus layer lining the respiratory tract with the motive of enhancing its clearance. Option B: Antitussives are drugs that suppress the cough reflex. Persistent coughing can be exhausting and can cause muscle strain and further irritation of the respiratory tract. They act on the cough-control center in the medulla to suppress the cough reflex. Option D: Antibiotics are powerful medicines that fight bacterial infections. They either kill bacteria or stop them from reproducing, allowing the body’s natural defenses to eliminate the pathogens. Used properly, antibiotics can save lives. But growing antibiotic resistance is curbing the effectiveness of these drugs. Taking an antibiotic as directed, even after symptoms disappear, is key to curing infection and preventing the development of resistant bacteria. 2. Question A client is receiving isoetharine hydrochloride (Bronkosol) via a nebulizer. The nurse monitors the client for which side effect of this medication? A. Constipation B. Diarrhea C. Bradycardia D. Tachycardia Correct Answer: D. Tachycardia Side effects that can occur from a beta 2 agonist include tremors, nausea, nervousness, palpitations, tachycardia, peripheral vasodilation, and dryness of the mouth or throat. Due to the vasodilatory effect of peripheral vasculature and subsequent decrease in cardiac venous return, compensatory mechanisms manifest as tachycardia are relatively common, especially within the first weeks of usage. Option A: Constipation is not a side effect of isoetharine. Beta-2 agonists have been shown to decrease serum potassium levels via an inward shift of potassium into the cells due to an effect on the membrane- bound Na/K-ATPase, which can potentially result in hypokalemia. Beta-2 agonists also promote glycogenolysis, which can lead to inadvertent elevations in serum glucose. Option B: Adverse effects of beta-2 agonists most commonly involve the desensitization of the beta-2 adrenergic receptor to the beta-2 agonist. Due to the similar properties between the classes of adrenergic receptors, beta-2 agonists can create an “off-target” effect in stimulating either alpha-1, alpha-2, or beta-1 receptors. The most common side effects of beta-2 agonists involve the cardiac, metabolic, or musculoskeletal system. Option C: Arrhythmias are seen more commonly in fenoterol usage versus albuterol, and arrhythmias have an increase in frequency in patients with underlying heart disease or concomitant theophylline use. Several studies have also indicated hypoxemia and hypercapnia as exacerbating factors to the cardiotoxic effects of beta-2 agonists. 3. Question A nurse teaches a client about the use of a respiratory inhaler. Which action by the client indicated a need for further teaching? A. Removes the cap and shakes the inhaler well before use. B. Press the canister down with your finger as he breathes in. C. Inhales the mist and quickly exhales. D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed. Correct Answer: C. Inhales the mist and quickly exhales. Take the inhaler out of the mouth. If the client can, he should hold his breath as he slowly counts to 10. This lets the medicine reach deep into the lungs. The client should be instructed to hold his or her breath at least 10 to 15 seconds before exhaling the mist. Option A: If the client has not used the inhaler in a while, he may need to prime it. See the instructions that came with the inhaler for when and how to do this. Shake the inhaler hard 10 to 15 times before each use. Option B: Hold the inhaler with the mouthpiece down. Place lips around the mouthpiece so that the mouth forms a tight seal. As the client starts to slowly breathe in through the mouth, press down on the inhaler one time. Option D: If using inhaled, quick-relief medicine (beta-agonists), wait about 1 minute before taking the next puff. You do not need to wait a minute between puffs for other medicines. 4. Question A female client is scheduled to have a chest radiograph. Which of the following questions is of most importance to the nurse assessing this client? A. “Is there any possibility that you could be pregnant?” B. “Are you wearing any metal chains or jewelry?” C. “Can you hold your breath easily?” D. “Are you able to hold your arms above your head?” Correct Answer: A. “Is there any possibility that you could be pregnant?” The most important item to ask about is the client’s pregnancy status because pregnant women should not be exposed to radiation. The risk of side effects of an X-ray while the client is pregnant is extremely minimal, but it is always important to protect the developing fetus from harm. Option B: Clients are also asked to remove any chains or metal objects that could interfere with obtaining an adequate film. The client may be asked to strip down and wear a hospital gown, or at least remove clothing on the part of the body that needs to be X-rayed. Option C: A chest radiograph most often is done at full inspiration, which gives optimal lung expansion. Option D: If a lateral view of the chest is ordered, the client is asked to raise the arms above the head. The client will be asked to stay still so the image will be as clear as possible. This will provide the most accurate image. Most films are done in posterior-anterior view. The X-ray test works by positioning the part of the body being X-rayed between the source of the X-ray and an X-ray detector (such as a film). 5. Question A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? Encouraging additional fluids for the next 24 hours Ensuring the return of the gag reflex before offering foods or fluids Administering atropine intravenously Administering small doses of midazolam (Versed). Correct Answer: B. Ensuring the return of the gag reflex before offering foods or fluids After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and the local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Although bronchoscopy can be done without sedation, most procedures are done under moderate conscious sedation with the use of various sedatives based on the clinician’s preference (e.g., benzodiazepines, opioids, dexmedetomidine). Option A: Additional fluids are unnecessary because no contrast dye is used that would need to be flushed from the system. Regardless of the sedation or anesthesia used the physicians should be aware of the potential side effects and how to manage patients receiving these medications. Option C: Atropine would be administered before the procedure, not after. Atropine premedication is widely used for fiberoptic bronchoscopy and may help by drying secretions, producing bronchodilation, or preventing vasovagal reactions. Option D: The administration of additional midazolam in small doses, until the target sedation level is achieved, is a safe procedure that is associated with significantly less discomfort and pain during bronchoscopy and a greater consent to re?examination when compared with the administration of a fixed dose of midazolam. 6. Question A client has an order to have radial ABG drawn. Before drawing the sample, a nurse occludes the: Brachial and radial arteries, and then releases them and observes the circulation of the hand. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery. Radial artery and observes for color changes in the affected hand. Ulnar artery and observes for color changes in the affected hand. Correct Answer: B. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery. Before drawing an ABG, the nurse assesses the collateral circulation to the hand with Allen’s test. This involves compressing the radial and ulnar arteries and asking the client to close and open the fist. This should cause the hand to become pale. The nurse then releases pressure on one artery and observes whether circulation is restored quickly. The nurse repeats the process, releasing the other artery. The blood sample may be taken safely if collateral circulation is adequate. Option A: Puncture of the radial artery is usually preferred because of the accessibility of the vessel, the presence of collateral circulation, and the artery’s superficial course proximal to the wrist, which makes it easier for the clinician to identify the vascular structure and hold local pressure after the procedure is finished. Option C: The radial artery is most easily accessible medial to the radial styloid process and lateral to the flexor carpi radialis tendon, 2-3 cm proximal to the ventral surface of the wrist crease. Firm occlusive pressure is held on both the radial artery and the ulnar artery. The patient is asked to clench the fist several times until the palmar skin is blanched, then to unclench the fist. Option D: If radial artery sampling is not feasible, femoral artery puncture is a possible alternative. When femoral artery puncture is being considered, the potential risk of infection at the entry site and the artery’s proximity to the femoral vein and nerve must be taken into 7. Question A nurse is assessing a client with chronic airflow limitation and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitation? Chronic obstructive bronchitis Emphysema Bronchial asthma Bronchial asthma and bronchitis Correct Answer: B. Emphysema The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, which is referred to as “barrel chest.” The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion. Option A: Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) that is defined as a productive cough of more than 3 months occurring within a span of 2 years. Patients typically present with chronic productive cough, malaise, and symptoms of excessive coughing such as chest or abdominal pain. Option C: Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration. Option D: Acute bronchitis is the result of acute inflammation of the bronchi secondary to various triggers, most commonly viral infection, allergens, pollutants, etc. Inflammation of the bronchial wall leads to mucosal thickening, epithelial-cell desquamation, and denudation of the basement membrane. At times, a viral upper respiratory infection can progress to infection of the lower respiratory tract resulting in acute bronchitis. 8. Question A client has been taking benzonatate (Tessalon Perles) as prescribed. A nurse concludes that the medication is having the intended effect if the client experiences: Decreased anxiety level. Increased comfort level. Reduction of N/V. Decreased frequency and intensity of cough. Correct Answer: D. Decreased frequency and intensity of cough. Benzonatate is a locally acting antitussive the effectiveness of which is measured by the degree to which it decreases the intensity and frequency of cough without eliminating the cough reflex. Benzonatate is an oral antitussive drug used in the relief and suppression of cough in patients older than ten years of age. Currently, benzonatate is the only non-narcotic antitussive available as a prescription drug. It works to reduce the activity of cough reflex by desensitizing the tissues of the lungs and pleura involved in the cough reflex. Option A: Because its chemical structure resembles that of the anesthetic agents in the para-amino-benzoic acid class (such as [procaine] and [tetracaine]), benzonatate exhibits anesthetic or numbing action. Although it is not prone to drug misuse or abuse, benzonatate is associated with a risk for severe toxicity and overdose, especially in children. Option B: Benzonatate suppresses cough associated with both acute and chronic respiratory conditions. It works by desensitizing the pulmonary stretch receptors involved in the cough reflex. There are limited clinical trials of benzonatate; however, earlier studies demonstrated inhibition of experimentally-induced cough and subjectively-measured pathological cough by benzonatate. Option C: Benzonatate is a synthetic butylamino-benzoate derivative related to tetracaine and a peripherally acting antitussive, non narcotic Benzonatate reduces the cough reflex by anesthetizing and depressing mechanoreceptors in the respiratory passages, lungs, and pleura. It is recommended for cough relief in the common cold, bronchitis, pneumonia, and for chronic cough such as in asthma. 9. Question Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will: Maintain a fluid intake of 800 ml every 24 hours. Experience chills only once a day. Cough productively without chest discomfort. Experience less nasal obstruction and discharge. Correct Answer: D. Experience less nasal obstruction and discharge. A client recovering from an URI should report decreasing or no nasal discharge and obstruction. Decongestants and combination antihistamine/decongestant medications can limit cough, congestion, and other symptoms in adults. Avoid cough preparations in children. H1-receptor antagonists may offer a modest reduction of rhinorrhea and sneezing during the first 2 days of a cold in adults. Option A: Daily fluid intake should be increased to more than 1 L every 24 hours to liquefy secretions. Topical and oral nasal decongestants (i.e., topical oxymetazoline, oral pseudoephedrine) have moderate benefit in adults and adolescents in reducing nasal airway resistance. Evidence-based data does not support the use of antibiotics in the treatment of the common cold because they do not improve symptoms or shorten the course of illness. Option B: The temperature should be below 100*F (37.8*C) with no chills or diaphoresis. According to a Cochrane Review, vitamin C used as daily prophylaxis at doses of =0.2 grams or more had a “modest but consistent effect” on the duration and severity of common cold symptoms (8% and 13% decreases in duration for adults and children, respectively). Option C: A productive cough with chest pain indicated pulmonary infection, not an URI. The presence of classical features for rhinovirus infection, coupled with the absence of signs of bacterial infection or serious respiratory illness, is sufficient to make the diagnosis of the common cold. The common cold is a clinical diagnosis, and diagnostic testing is not necessary. 10. Question Which of the following individuals would the nurse consider to have the highest priority for receiving an influenza vaccination? A 60-year-old man with a hiatal hernia. A 36-year-old woman with 3 children. A 50-year-old woman caring for a spouse with cancer. A 60-year-old woman with osteoarthritis. Correct Answer: C. A 50-year-old woman caring for a spouse with cancer. Individuals who are household members or home care providers for high-risk individuals are high-priority targeted groups for immunization against influenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for a husband with cancer has the highest priority of the clients described. Option A: In certain groups, including the elderly, immune-compromised individuals and infants, the influenza vaccine is less effective, but it is beneficial by reducing the incidence of severe disease, like bronchopneumonia, and reduces hospital admission and mortality. Option B: Regarding immunization in pregnancy, a randomized controlled trial conducted in South Africa has shown that when pregnant women receive the influenza vaccine, it halves their risk of developing influenza while reducing the risk of their infants (up to 24 weeks) contracting the illness. Option D: Influenza vaccine conveys immunity against the influenza virus by stimulating the production of antibodies specific to the disease. Antibodies to NA act by aggregating viruses on the cell surface effectively and reducing the amount of virus released from infected cells. 11. Question A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client? A. “Use your nasal decongestant spray regularly to help clear your nasal passages.” B. “Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.” C. “It is important to increase your activity. A daily brisk walk will help promote drainage.” D. “Keep a diary when your symptoms occur. This can help you identify what precipitates your attacks.” Correct Answer: D. “Keep a diary when your symptoms occur. This can help you identify what precipitates your attacks.” It is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Patients often underestimate the severity of this condition and fail to seek medical therapy. It is important to adequately control AR, especially due to the link between AR and asthma, with poor control of rhinitis predicting poor control of asthma. Option A: Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. If removing a pet from home is not feasible, isolating the pet to a single room in the house may be an option to minimize dander exposure. It may take up to 20 weeks to eliminate cat dander from home even after removing the animal. Option B: Antibiotics are not appropriate. Intranasal corticosteroid therapy can be as monotherapy or in combination with oral antihistamines in patients with mild, moderate, or severe symptoms. Studies have shown intranasal corticosteroids are superior to antihistamines in effectively reducing nasal inflammation and improving mucosal pathology. Option C: Increasing activity will not control the client’s symptoms; in fact, walking outdoors may increase them if the client is allergic to pollen. Avoidance of triggers, especially in those with seasonal symptoms, is encouraged, although it is not always practical. Precautions can be taken to avoid dust mites, animal dander, and upholstery, though this can require significant lifestyle changes that may not be acceptable to the patient. 12. Question An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she developed a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings? A. It is likely that the client is developing a secondary bacterial pneumonia. B. The assessment findings are consistent with influenza and are to be expected. C. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions D. The client has not been taking her decongestants and bronchodilators as prescribed. Correct Answer: A. It is likely that the client is developing a secondary bacterial pneumonia. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection that is not consistent with a diagnosis of influenza. Option B: Diagnosis of influenza can be reached clinically, especially during the influenza season. Most of the cases will recover without medical treatment, and they would not need a laboratory test for the diagnosis. Signs and symptoms of influenza in mild cases include a cough, fever, sore throat, myalgia, headache, runny nose, and congested eyes. A frontal or retro-orbital headache is a common presentation with selected ocular symptoms that include photophobia and pain with different qualities. Option C: These findings are not indicative of dehydration. The clinical presentation of influenza ranges from mild to severe depending on the age, comorbidities, vaccination status, and natural immunity to the virus. Usually, patients who received the seasonal vaccine present with milder symptoms, and they are less likely to develop complications. Option D: Decongestants and bronchodilators are not typically prescribed for the flu. Influenza infection is self-limited and mild in most healthy individuals who do not have other comorbidities. No antiviral treatment is needed during mild infections in healthy individuals. Antiviral medications can be used to treat or prevent influenza infection, especially during outbreaks in healthcare settings such as hospitals and residential institutions. 14. Question Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible side effect of this drug? A. Constipation B. Bradycardia C. Diplopia D. Restlessness Correct Answer: D. Restlessness Side effects of pseudoephedrine are experienced primarily in the cardiovascular system and through sympathetic effects on the CNS. The most common CNS effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular side effects include tachycardia, hypertension, palpitations, and arrhythmias. Option A: Pseudoephedrine is used to relieve nasal congestion caused by colds, allergies, and hay fever. It is also used to temporarily relieve sinus congestion and pressure. Pseudoephedrine will relieve symptoms but will not treat the cause of the symptoms or speed recovery. Pseudoephedrine is in a class of medications called nasal decongestants. It works by causing narrowing of the blood vessels in the nasal passages. Option B: Tachycardia, not bradycardia, is a side effect of pseudoephedrine. Nonprescription cough and cold combination products, including products that contain pseudoephedrine, can cause serious side effects or death in young children. Do not give nonprescription pseudoephedrine products to children younger than 4 years of age. Option C: Diplopia is not a side effect of pseudoephedrine. Tell your doctor if you have or have ever had high blood pressure, glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision), diabetes, difficulty urinating (due to an enlarged prostate gland), or thyroid or heart disease. If you plan to take the 24-hour extended-release tablets, tell your doctor if you have had a narrowing or blockage of your digestive system. 15. Question A client with COPD reports steady weight loss and being “too tired from just breathing to eat.” Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client? A. Altered nutrition: Less than body requirements related to fatigue. B. Activity intolerance related to dyspnea. C. Weight loss related to COPD. D. Ineffective breathing pattern related to alveolar hypoventilation. Correct Answer: A. Altered nutrition: Less than body requirements related to fatigue. The client’s problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Instruct the patient to frequently eat high caloric foods in smaller portions. COPD patients expend an extraordinary amount of energy simply on breathing and require high caloric meals to maintain body weight and muscle mass. Option B: Activity intolerance is a likely diagnosis but is not related to the client’s nutritional problems. Provide at least 90 minutes of undisturbed rest in between activities. Allotment of undisturbed rest reduces demand for oxygen and allows adequate physiologic recovery. Option C: Weight loss is not a nursing diagnosis. Encourage a rest period of 1 hr before and after meals. Helps reduce fatigue during mealtime and provides an opportunity to increase total caloric intake. Avoid gas-producing foods and carbonated beverages. Can produce abdominal distension, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea. Option D: Ineffective breathing pattern may be a problem, but this diagnosis does not specifically address the problem of weight loss described by the client. Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over the body as appropriate. Promotes physiological ease of maximal inspiration. 16. Question When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following? A. Develop infections easily. B. Maintain current status. C. Require less supplemental oxygen. D. Show permanent improvement. Correct Answer: A. Develop infections easily. A client with COPD is at high risk for development of respiratory infections. In emphysema, an irritant (e.g., smoking) causes an inflammatory response. Neutrophils and macrophages are recruited and release multiple inflammatory mediators. Oxidants and excess proteases leading to the destruction of the air sacs. The protease-mediated destruction of elastin leads to a loss of elastic recoil and results in airway collapse during exhalation. Option B: COPD is slowly progressive; therefore, maintaining current status is an unrealistic expectation. COPD is an inflammatory condition involving the airways, lung parenchyma, and pulmonary vasculature. The process is thought to involve oxidative stress and protease-antiprotease imbalances. Emphysema describes one of the structural changes seen in COPD where there is destruction of the alveolar air sacs (gas- exchanging surfaces of the lungs) leading to obstructive physiology. Option C: This is an unrealistic expectation. The prognosis of COPD is variable based on adherence to treatment including smoking cessation and avoidance of other harmful gases. Patients with other comorbidities (e.g., pulmonary hypertension, cardiovascular disease, lung cancer) typically have a poorer prognosis. The airflow limitation and dyspnea are usually progressive. Option D: Treatment may slow progression of the disease, but permanent improvement is highly unlikely. As the disease progresses, impairment of gas exchange is often seen. The reduction in ventilation or increase in physiologic dead space leads to CO2 retention. Pulmonary hypertension may occur due to diffuse vasoconstriction from hypoxemia. 17. Question Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client: A. Promises to do pursed lip breathing at home. B. States actions to reduce pain. C. States that he will use oxygen via a nasal cannula at 5 L/minute. D. Agrees to call the physician if dyspnea on exertion increases. Correct Answer: D. Agrees to call the physician if dyspnea on exertion increases. Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD, and therefore the physician should be notified. There are things that everyone with COPD should do to manage their disease; quitting smoking (if they smoke) is the most important. In addition, there are other non- medication treatments that can help relieve symptoms and improve quality of life. Option A: Extracting promises from clients is not an outcome criterion. Pulmonary rehabilitation programs have been shown to improve a person’s ability to exercise, enhance quality of life, and decrease the frequency of COPD exacerbations (when symptoms flare up more than usual). Even people with severe shortness of breath can benefit from a rehabilitation program. Option B: Pain is not a common symptom of COPD. Although COPD usually worsens over time, it is difficult to predict how quickly it will progress and how long the client will live (the prognosis). A number of factors play a role in the severity of COPD symptoms, including whether the client continues to smoke, are underweight, or have other medical problems, and how the lungs function during exercise. People with COPD who have less severe symptoms, are a healthy weight, and do not smoke tend to live longer. Option C: Clients with COPD use low-flow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia. People with severe or advanced COPD can have low oxygen levels in the blood. This condition, known as hypoxemia, can occur even if the client does not feel short of breath or have other symptoms. The oxygen level can be measured with a device placed on the finger (pulse oximeter) or with a blood test (arterial blood gas). People with hypoxemia may be placed on oxygen therapy, which can improve survival and quality of life. 18. Question Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD? A. Increased anteroposterior chest diameter. B. Underdeveloped neck muscles. C. Collapsed neck veins. D. Increased chest excursions with respiration. Correct Answer: A. Increased anteroposterior chest diameter. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. In addition, coarse crackles beginning with inspiration may be heard. Option B: Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign). Option C: Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump into pulmonary vasculature. In advanced disease, cyanosis, elevated jugular venous pulse (JVP), and peripheral edema can be observed. Option D: Diminished, not increased, chest excursion is associated with COPD. The sensitivity of a physical examination in detecting mild to moderate COPD is relatively poor; however, physical signs are quite specific and sensitive for severe disease. Patients with severe disease experience tachypnea and respiratory distress with simple activities. 19. Question Which of the following is the primary reason to teach pursed-lip breathing to clients with emphysema? A. To promote oxygen intake. B. To strengthen the diaphragm. C. To strengthen the intercostal muscles. D. To promote carbon dioxide elimination. Correct Answer: D. To promote carbon dioxide elimination. Pursed lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonged exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles. Option A: For those suffering from chronic obstructive pulmonary disease, the ability to take in oxygen is a constant struggle. It’s possible to increase oxygen levels in other ways, such as cellular therapy. Cellular therapy may promote the healing of lung tissue, potentially improving lung function. When lung function improves, the client is able to take in more oxygen as well as expel carbon dioxide because the lungs are working more effectively. Option B: Diaphragmatic breathing is a type of a breathing exercise that helps strengthen the diaphragm, an important muscle that helps us breathe. This breathing exercise is also sometimes called belly breathing or abdominal breathing. Option C: Breathing exercises slowly fill the lungs with air to expand the chest and work the intercostal muscles. To do this exercise, it is typically recommended to sit or stand with the back straight, then take a full breath from the bottom of the lungs. It can help to think of breathing from the diaphragm, by slowly expanding the abdominal muscles while inhaling, then pushing air from the lungs using these same muscles. 20. Question Which of the following is a priority goal for the client with COPD? A. Maintaining functional ability. B. Minimizing chest pain. C. Increasing carbon dioxide levels in the blood. D. Treating infectious agents. Correct Answer: A. Maintaining functional ability A priority goal for the client with COPD is to manage the s/s of the disease process so as to maintain the client’s functional ability. Evaluate the level of activity tolerance. Provide a calm, quiet environment. Limit a patient’s activity or encourage bed or chair rest during the acute phase. Have patient resume activity gradually and increase as individually tolerated. Option B: Chest pain is not a typical sign of COPD. Assess and record respiratory rate, depth. Note the use of accessory muscles, pursed-lip breathing, inability to speak or converse. Useful in evaluating the degree of respiratory distress or chronicity of the disease process. Option C: The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Monitor arterial blood gasses values as ordered. As the patient’s condition progresses, Pa02 usually decreases. For patients with chronic carbon dioxide retention may have chronically compensated respiratory acidosis with a low normal pH and a PaCo2 higher than 50 mm Hg. Option D: Preventing infection would be a goal of care for the client with COPD. Demonstrate and assist the patient in the disposal of tissues and sputum. Stress proper handwashing (nurse and patient), and use gloves when handling or disposing of tissues, sputum containers. Prevents spread of fluid-borne pathogens. 21. Question A client’s arterial blood gas levels are as follows: pH 7.31; PaO2 80 mm Hg, PaCO2 65 mm Hg; HCO3- 36 mEq/L. Which of the following signs or symptoms would the nurse expect? A. Cyanosis B. Flushed skin C. Irritability D. Anxiety Correct Answer: B. Flushed skin The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the CNS. On the contrary, chronic respiratory acidosis may be caused by COPD where there is a decreased responsiveness of the reflexes to states of hypoxia and hypercapnia. Option A: Cyanosis is a late sign of hypoxia. In respiratory acidosis, the slight increase in bicarbonate serves as a buffer for the increase in H+ ions, which helps minimize the drop in pH. In some cases, patients may present with cyanosis due to hypoxemia. Option C: Irritability is not common with a PaCO2 level of 65 mm Hg but is associated with hypoxia. If the respiratory acidosis is severe and accompanied by prolonged hypoventilation, the patient may have additional symptoms such as altered mental status, myoclonus, and possibly even seizures. Option D: The clinical presentation of respiratory acidosis is usually a manifestation of its underlying cause. Signs and symptoms vary based on the length, severity, and progression of the disorder. Patients can present with dyspnea, anxiety, wheezing, and sleep disturbances. 22. Question When teaching a client with COPD to conserve energy, the nurse should teach the client to lift objects: A. While inhaling through an open mouth. B. While exhaling through pursed lips. C. After exhaling but before inhaling. D. While taking a deep breath and holding it. Correct Answer: B. While exhaling through pursed lips. Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. When one practices regularly, breathing exercises can help exert oneself less during daily activities. They can also potentially aid in return to exercising, which can lead to feeling more energetic overall. Option A: Pursing the lips prolongs exhalation and provides the client with more control over breathing. It’s been shown to reduce how hard one has to work to breathe. It helps release air trapped in the lungs. It promotes relaxation. It reduces shortness of breath. Option C: Lifting after exhalation but before inhaling is similar to lifting with the breath held. The purpose of pursed lip breathing is to help keep the airways open. This helps your airways to remain open. Pursed lip breathing also slows down the breathing rate and calms the patient down. Option D: This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac dysrhythmias. The purpose of coordinated breathing is to help assure adequate oxygen to the working muscles and to prevent the client from holding the breath. 23. Question The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of the following s/s would be included in the teaching plan? A. Clubbing of nail beds B. Hypertension C. Peripheral edema D. Increased appetite Correct Answer: C. Peripheral edema Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Right heart failure is most commonly a result of left ventricular failure via volume and pressure overload. Clinically, patients will present with signs and symptoms of chest discomfort, breathlessness, palpitations, and body swelling. Option A: Clubbing of nail beds is associated with conditions of chronic hypoxia. Clubbing is a medical condition first described by Hippocrates in which the fingers (and/or toes) have the appearance of upside- down spoons. It is caused by a build-up of tissue in the distant part of the fingers (terminal phalanges), that causes the end of the fingers to become enlarged and the nails to curve downward. Option B: Hypertension is associated with left-sided heart failure. When hemodynamic instability is present, vasopressors are indicated. Norepinephrine is the pressor of choice to improve systemic hypotension and restore cerebral, cardiac and end-organ perfusion. Option D: Clients with heart failure have decreased appetites. A poor appetite can also result from the accumulation of fluid in the liver and digestive system. Fluid accumulation, edema, is a common symptom of heart failure. The accumulation of fluid that is responsible for the abdominal swelling can decrease the appetite and result in nausea as well as discomfort from the weight gain. 24. Question The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which of the following findings would be expected? A. Normal breath sounds B. Prolonged inspiration C. Normal chest movement D. Coarse crackles and rhonchi Correct Answer: D. Coarse crackles and rhonchi Exacerbations of COPD are frequently caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. Crackles are usually due to airway secretions within a large airway and disappear on coughing. These crackles are scanty, gravity-independent, usually audible at the mouth, and strongly associated with severe airway obstruction. Option A: In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. A reduction in breath sound intensity (BSI) is often seen in patients with COPD. Pardee et al. developed a scoring system for BSI. According to this system, the clinician listens sequentially over six locations on the patient’s chest: bilaterally over the upper anterior portion of the chest, in the midaxillary, and at the posterior bases. Option B: Expiration, not inspiration, becomes prolonged. Patients with COPD often present with diminished breath sounds, prolonged expiratory time, and expiratory wheezing that initially may occur only on forced expiration. Option C: Chest movement is decreased as lungs become overdistended. Additional findings on physical examination include hyperinflation of the lungs with an increased anteroposterior chest diameter (“barrel chest”); use of accessory muscles of respiration; and distant heart sounds, sometimes best heard in the epigastrium. 25. Question Which of the following ABG abnormalities should the nurse anticipate in a client with advanced COPD? A. Increased PaCO2 B. Increased PaO2 C. Increased pH D. Increased oxygen saturation Correct Answer: A. Increased PaCO2 As COPD progresses, the client typically develops increased PaCO2 levels and decreased PaO2 levels. This results in decreased pH and decreased oxygen saturation. These changes are the result of air trapping and hypoventilation. Arterial blood gas (ABG) analysis provides the best clues as to acuteness and severity of disease exacerbation. Option B: Patients with mild COPD have mild to moderate hypoxemia without hypercapnia. As the disease progresses, hypoxemia worsens and hypercapnia may develop, with the latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the predicted value. Lung mechanics and gas exchange worsen during acute exacerbations. Option C: In general, renal compensation occurs even in chronic CO2 retainers (ie, bronchitis); thus, pH usually is near normal. Generally, consider any pH below 7.3 to be a sign of acute respiratory compromise. Option D: The compensation to respiratory acidosis consists in a secondary increase in bicarbonate concentration, and the arterial blood gas analysis is characterized by a reduced pH, increased pCO2 (initial variation), and increased bicarbonate levels (compensatory response). 26. Question Which of the following diets would be most appropriate for a client with COPD? A. Low fat, low cholesterol B. Bland, soft diet C. Low-Sodium diet D. High calorie, high-protein diet Correct Answer: D. High-calorie, high-protein diet The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. Eat 20 to 30 grams of fiber each day, from items such as bread, pasta, nuts, seeds, fruits and vegetables. Eat a good source of protein at least twice a day to help maintain strong respiratory muscles. Good choices include milk, eggs, cheese, meat, fish, poultry, nuts and dried beans or peas. Option A: A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. Choose mono- and poly-unsaturated fats, which do not contain cholesterol. These are fats that are often liquid at room temperature and come from plant sources, such as canola, safflower and corn oils. Option B: Metabolism of carbohydrates produces the most carbon dioxide for the amount of oxygen used; metabolism of fat produces the least. For some people with COPD, eating a diet with fewer carbohydrates and more fat helps them breathe easier. Option C: The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. Choose complex carbohydrates, such as whole-grain bread and pasta, fresh fruits, and vegetables. Limit simple carbohydrates, including table sugar, candy, cake, and regular soft drinks. 27. Question The nurse is planning to teach a client with COPD how to cough effectively. Which of the following instructions should be included? A. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation. B. Lie flat on back, splint the thorax, take two deep breaths and cough. C. Take several rapid, shallow breaths and then cough forcefully. D. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing. Correct Answer: A. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation. The goal of effective coughing is to conserve energy, facilitate the removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process 3 or 4 times, the client should take a deep abdominal breath, bend forward and cough 3 or 4 times upon exhalation (“huff” cough). Option B: Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Sit on a chair or on the edge of the bed, with both feet on the floor. Lean slightly forward. Relax. The patient should breathe in through their nose and out through their nose or mouth until they are ready to progress to the next stage. Option C: Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. The client should lean forward, press the arms against the abdomen. Cough 2-3 times through a slightly open mouth. Coughs should be short and sharp. The first cough loosens the mucus and moves it through the airways. The second and third cough enables the client to cough the mucus up and out. Option D: A side-lying position does not allow for adequate chest expansion to promote deep breathing. Sitting the patient out of bed or up in bed optimizes lung expansion. Critical care patients can sit out of bed if they are hemodynamically stable (this allows for better lung expansion). Ensure you have two to three clinicians assisting with any intravenous lines, cardiac monitoring, drain tubes, etc. 28. Question A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client? A. Initiate oxygen therapy and reassess the client in 10 minutes. B. Draw blood for an ABG analysis and send the client for a chest x-ray. C. Encourage the client to relax and breathe slowly through the mouth. D. Administer bronchodilators. Correct Answer: D. Administer bronchodilators. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, intravenous corticosteroids, and possibly intravenous theophylline. Option A: Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention. A favorable response to initial treatment of status asthmaticus should be a visible improvement in symptoms that sustains 30 minutes or beyond the last bronchodilator dose and a PEFR greater than 70% of predicted. Option B: Drawing an ABG and obtaining a chest x-ray would be a delay. The absolute value of PEFR less than 120 L per minute and FEV1 less than 1 L corresponds with the proportional reduction. These absolute numbers should prompt an assessment of arterial blood gas (ABG) immediately. Initial blood gas results indicate respiratory alkalosis with hypoxemia. Option C: It would be futile to encourage the client to relax and breathe slowly without providing necessary pharmacologic intervention. An initial aggressive treatment trial of beta-agonists, corticosteroids, and anticholinergics has to be tried, followed by adjunct measures, which may not be based on robust guidelines but evidence. 29. Question The nurse would anticipate which of the following ABG results in a client experiencing a prolonged, severe asthma attack? A. Decreased PaCO2, increased PaO2, and decreased pH. B. Increased PaCO2, decreased PaO2, and decreased pH. C. Increased PaCO2, increased PaO2, and increased pH. D. Decreased PaCO2, decreased PaO2, and increased pH. Correct Answer: B. Increased PaCO2, decreased PaO2, and decreased pH. As the severe asthma attack worsens, the client becomes fatigued and alveolar hypotension develops. This leads to carbon dioxide retention and hypoxemia. The client develops respiratory acidosis. Therefore, the PaCO2 level increases, the PaO2 level decreases, and the pH decreases, indicating acidosis. Option A: Respiratory acidosis is a very common acid-base disturbance in acute severe asthma and is widely considered to be an ominous finding. Its early recognition and treatment are important and decisive for the final outcome, as it can lead to respiratory failure and arrest if prolonged. Option C: Hypercapnia in asthma, in addition to the severity of the disease, is also associated with the therapeutic administration of oxygen. Thus, in patients with severe asthma exacerbation, a significant increase (?4 mmHg) in transcutaneous PCO2 (PtCO2) was observed in a higher proportion in those receiving high oxygen mixtures (>8 L/min), compared to those who received titrated oxygen (to achieve oxygen saturation of 93–95%) Option D: Lee et al. noted that PaCO2 was significantly higher and the arterial blood pH lower in asthmatics who died, and delays in providing mechanical ventilation led to worse outcomes. Another mechanism implicates the Haldane effect, in which oxygen displaces the CO2 dissociation curve to the right, increasing PaCO2, which cannot be normalized as patients with severe COPD are unable to increase ventilation. 30. Question A client with acute asthma is prescribed short-term corticosteroid therapy. What is the rationale for the use of steroids in clients with asthma? A. Corticosteroids promote bronchodilation.  B. Corticosteroids act as an expectorant. C. Corticosteroids have an anti-inflammatory effect. D. Corticosteroids prevent development of respiratory infections. Correct Answer: C. Corticosteroids have an anti-inflammatory effect. Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. At a physiologic level, steroids reduce airway inflammation and mucus production and potentiate beta-agonist activity in smooth muscles and reduce beta-agonists tachyphylaxis in patients with severe asthma. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections. Option A: Short-acting inhaled beta-agonists are the drug of the first choice in acute asthma. Albuterol is preferred over metaproterenol in that class because of its higher beta 2 selectivities and longer duration of action. The dose-response curve and duration of action of these medications are adversely affected by a combination of patient factors, including pre existing bronchoconstriction, airway inflammation, mucus plugging, poor patient effort, and coordination. Option B: Anticholinergics have a variable response in acute exacerbation with a somewhat underwhelming bronchodilatory role. However, they can be useful in patients with bronchospasm induced by beta-blockade or severe underlying obstructive disease with FEV1 less than 25% of predicted. Option D: Graham et al. conducted a randomized double-blinded trial and demonstrated no difference in improvement in symptom score, spirometry, or length of hospitalization with routine use of antibiotics in status asthmaticus. That does not mean that patients with clinical signs of infection should not be treated with antimicrobials, or due diligence should not be pursued in obtaining respiratory culture specimens early on. 31. Question The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. A. The inhaler is held upright. B. Head is tilted down while inhaling the medication. C. Client waits 5 minutes between puffs. D. Mouth is rinsed with water following administration. E. Client lies supine for 15 minutes following administration. Correct Answers: A & D. Inhaled respiratory medications are often taken by using a device called a metered-dose inhaler, or MDI. The MDI is a pressurized canister of medicine in a plastic holder with a mouthpiece. When sprayed, it gives a reliable, consistent dose of medication. Option A: Remove the cap and hold the inhaler upright. Each inhaler consists of a small canister of medicine connected to a mouthpiece. The canister is pressurized. As the client presses down on the inhaler, it releases a mist of medicine. The client breathes that mist into the lungs. It’s important to use the inhaler correctly. Option B: Tilt the head back slightly and breathe out all the way. Keep the chin up and the inhaler upright (not aimed at the roof of the mouth or the tongue). Option C: Repeat puffs as directed by the doctor. Wait 1 minute before taking the second puff. A delay of 10–20 minutes between successive doses of the bronchodilator drug has been suggested in order to let the first act to improve the penetration and effect of the second dose, but again the evidence that this works is inconclusive. Many patients may forget to take a second dose with such a long interval. Option D: Some inhalers (steroid) also recommend rinsing the mouth out with water and gargling with water (spit out the water) after use. If using this inhaler for a corticosteroid preventer medication, with or without a spacer, rinse the mouth with water and spit after inhaling the last dose to reduce the risk of side- effects Option E: The client does not have to be in the supine position after administration. Proper instruction by a trained person with a placebo aerosol is essential to teach the correct inhaler technique. This should be followed subsequently by regular checks to locate any faults that may develop. Inevitably, some patients will be unable to use an MDI, and for them, spacer attachments, or dry powder inhalers are preferable since they place fewer demands on patients’ skill. Even these devices, however, must be used properly to achieve a satisfactory effect. 32. Question A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler (MDI), two puffs every 4 hours. The nurse instructs the client to report side effects. Which of the following are potential side effects of metaproterenol? A. Irregular heartbeat B. Constipation C. Pedal edema D. Decreased heart rate. Correct Answer: A. Irregular heartbeat Irregular heart rates should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on the beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia. Option B: In children, the most common side effects are diarrhea, nausea, laryngitis, pharyngitis, sinusitis, otitis, and viral infection. The most commonly observed side effects in patients aged 15 years and over were headaches, influenza infection, abdominal pain, cough, and dyspepsia. Option C: There are some reports of serious adverse events due to angioedema, hypersensitivity, fatigue, confusional state, abnormal dreams, epilepsy, aggression, immune system disorder, hemorrhage, excoriation, eosinophil count increase, pain in extremity, and abdominal pain. Option D: Tell the doctor right away if any of these unlikely but serious side effects occur: fast/pounding/irregular heartbeat, muscle cramps, weakness. 33. Question A client has been taking flunisolide (Aerobid), two inhalations a day, for treatment of asthma. He tells the nurse that he has painful, white patches in his mouth. Which response by the nurse would be the most appropriate? A. “This is an anticipated side-effect of your medication. It should go away in a couple of weeks.” B. “You are using your inhaler too much and it has irritated your mouth.” C. “You have developed a fungal infection from your medication. It will need to be treated with an antifungal.” D. “Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem.” Correct Answer: C. “You have developed a fungal infection from your medication. It will need to be treated with an antifungal.” Use of oral inhalant corticosteroids, such as flunisolide, can lead to the development of oral thrush, a fungal infection. Oral candidiasis (thrush) is another common complaint among users of inhaled corticosteroids (ICS). This risk increases in elderly patients and patients who are also taking oral steroids, high dose ICS, or antibiotics. Option A: Once developed, thrush must be treated by antibiotic therapy; it will not resolve on its own. It is advisable to have the patient rinse their mouth out after ICS use to prevent oral candidiasis. Treatments for candidiasis include clotrimazole, miconazole, and nystatin. Option B: Fungal infections can develop even without overuse of the corticosteroid inhaler. Attention to dosage is required as the amount of Candida increased with dose of fluticasone. Gargling with a 1:50 dilution of amphotericin B is effective in treating oral candidiasis of asthmatic patients treated with inhaled steroids. Option D: Although good oral hygiene can help prevent the development of a fungal infection, it cannot be used alone to treat the problem. Most cases of oral thrush will clear up in a couple of weeks. In general, a single dose of antifungal medication may be enough to cure the infection. 34. Question Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? A. Incorporate physical exercise as tolerated into the treatment plan. B. Monitor peak flow numbers after meals and at bedtime. C. Eliminate stressors in the work and home environment.  D. Use sedatives to ensure uninterrupted sleep at night. Correct Answer: A. Incorporate physical exercise as tolerated into the treatment plan. Physical exercise is beneficial and should be incorporated as tolerated into the client’s schedule. Peak flow numbers should be monitored daily, usually in the morning (before taking medication). Encourage breathing exercises and controlled breathing and relaxation. Prevents attack before it begins and increases ventilation. Option B: Peak flow does not need to be monitored after each meal. Monitor peaked expiratory flow rates and forced expiratory volume as taken by the respiratory therapist. The severity of the exacerbation can be measured objectively by monitoring these values. The peak expiratory flow rate is the maximum flow rate that can be generated during a forced expiratory maneuver with fully inflated lungs. Option C: Stressors in the client’s life should be modified but cannot be totally eliminated. Instruct folks to modify the home environment to reduce dust, exposure to pets and indoor plants, foods (peanut, egg), changing of filters. Option D: Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep. Schedule and provide rest periods in a calm peaceful environment. Promotes adequate rest and decreases stimuli. 35. Question The client with asthma should be taught which of the following is one of the most common precipitating factors of an acute asthma attack? A. Occupational exposure to toxins. B. Viral respiratory infections. C. Exposure to cigarette smoke. D. Exercising in cold temperatures. Correct Answer: B. Viral respiratory infections. The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations. Asthma is a condition of acute, fully reversible airway inflammation, often following exposure to an environmental trigger. The pathological process begins with the inhalation of an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial hypersensitivity, leads to airway inflammation and an increase in mucus production. This leads to a significant increase in airway resistance, which is most pronounced on expiration. Option A: Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Asthma comprises a range of diseases and has a variety of heterogeneous phenotypes. The recognized factors that are associated with asthma are a genetic predisposition, specifically a personal or family history of atopy (propensity to allergy, usually seen as eczema, hay fever, and asthma). Option C: Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Asthma also is associated with exposure to tobacco smoke and other inflammatory gases or particulate matter. Option D: Some asthmatic attacks are triggered by exercising in cold weather. The overall etiology is complex and still not fully understood, especially when it comes to being able to say which children with pediatric asthma will carry on to have asthma as adults (up to 40% of children have a wheeze, only 1% of adults have asthma), but it is agreed that it is a multifactorial pathology, influenced by both genetics and environmental exposure. 36. Question A female client comes into the emergency room complaining of SOB and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her VS are: 140/80, P 110, R 40. The physician orders ABG’s, results are as follows: pH: 7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3- 24 mEq/L; SaO2 86%. Considering these results, the first intervention is to: A. Begin mechanical ventilation. B. Place the client on oxygen. C. Give the client sodium bicarbonate. D. Monitor for pulmonary embolism. Correct Answer: B. Place the client on oxygen The pH (7.50) reflects alkalosis, and the low PaCO2 indicates the lungs are involved. The client should immediately be placed on oxygen via mask so that the SaO2 is brought up to 95%. Encourage slow, regular breathing to decrease the amount of CO2 she is losing. Option A: Mechanical ventilation may be ordered for acute respiratory acidosis. In patients who are not significantly encephalopathic and have no excessive secretions, noninvasive ventilation with CPAP or BIPAP can be a useful modality to support ventilation and avoid the need for anesthesia and sedation, as well as the risk of nosocomial infection with endotracheal intubation. Option C: Sodium bicarbonate would be given to reverse acidosis. Sodium bicarbonate infusion reduces plasma ionized calcium concentration in critically ill patients with metabolic acidosis. In vitro, bicarbonate concentration has a major effect reducing ionized calcium level in serum Option D: This client may have pulmonary embolism, so she should be monitored for this condition, but it is not the first intervention. A timely diagnosis of a pulmonary embolism (PE) is crucial because of the high associated mortality and morbidity, which may be prevented with early treatment. It is important to note that 30% of untreated patients with pulmonary embolism die, while only 8% die after timely therapy. 37. Question Basilar crackles are present in a client’s lungs on auscultation. The nurse knows that these are discrete, non continuous sounds that are: A. Caused by the sudden opening of alveoli. B. Usually more prominent during expiration. C. Produced by airflow across passages narrowed by secretions. D. Found primarily in the pleura. Correct Answer: A. Caused by the sudden opening of alveoli Basilar crackles are usually heard during inspiration and are caused by sudden opening of the alveoli. Basilar crackles are a bubbling or crackling sound originating from the base of the lungs. They may occur when the lungs inflate or deflate. They’re usually brief, and may be described as sounding wet or dry. Excess fluid in the airways causes these sounds. Option B: Bronchial sounds (also called tubular sounds) normally arise from the tracheobronchial tree and vesicular sounds normally arise from the finer lung parenchyma. Loud, harsh, and high pitched bronchial sounds are typically heard over the trachea or at the right apex. They are predominantly heard during expiration. Option C: Wheezes are musical sounds caused by air movement through constricted small airways, such as bronchioles. Wheezes and rhonchi, which have the same pathology and are separated only by pitch, are produced by the fluttering of narrowed airways and the air that flows through them. Option D: Fluid or air in the pleural space deflects sound waves away from the chest wall back into the lung and therefore breath sounds are reduced in intensity. 38. Question A cyanotic client with an unknown diagnosis is admitted to the E.R. In relation to oxygen, the first nursing action would be to: A. Wait until the client’s lab work is done. B. Not administer oxygen unless ordered by the physician. C. Administer oxygen at 2 L flow per minute. D. Administer oxygen at 10 L flow per minute and check the client’s nail beds. Correct Answer: C. Administer oxygen at 2 L flow per minute. Administer oxygen at 2 L/minute and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function. With prolonged oxygen therapy there is an increase in blood oxygen level, which suppresses peripheral chemoreceptors; depresses ventilator drive and increase in PCO2. high blood oxygen level may also disrupt the ventilation: perfusion balance (V/Q) and cause an increase in dead space to tidal volume ratio and increase in PCO2. Option A: This is the ‘gold standard’ monitor of ventilation. Arterial blood gases are needed to obtain accurate data, in particular, evidence of hypoventilation (raised PaCO2) as a reason for hypoxemia. Arterial blood gases may also give an indication of the metabolic effects of clinically important hypoxemia. Option B: Although history taking and clinical examination may clarify the diagnosis, oxygen at 40%–60% should be continued until blood gas results are available unless the patient is drowsy or is known to have had previous episodes of Hypercapnic respiratory failure. Option D: Low intravascular volume either due to acute blood loss as in trauma can result in poor oxygen transport and tissue hypoxia. So, these patients should be given high concentration oxygen to maintain oxygen saturation above 90% until arrival at an emergency department. This can be achieved in most cases by the use of approximately 40%–60% oxygen via a medium concentration mask at a flow rate of 4–10 l/ min. 39. Question Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified? A. Serosanguineous drainage from the puncture site. B. Increased temperature and blood pressure. C. Increased pulse and pallor. D. Hypotension and hypothermia. Correct Answer: C. Increased pulse and pallor Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually, no more than 1 L of fluid is removed at one time to prevent this from occurring. Option A: Complications include bleeding, pain, and infection at the point of needle entry. If the approach is made too high in the intercostal space damage to the coastal vasculature and nerve injury is possible. Option B: If too much fluid is removed or if the fluid is removed too rapidly (eg using negative pressure chambers) re-expansion (aka post-expansion) pulmonary edema may occur. Removal of significant fluid volumes may also induce vasovagal physiology. Option D: If the procedural needle/catheter is passed through diseased tissue prior to entering the chest cavity, that process can be extended into the chest space. For example, passing the needle through thoracic or pleural tumor can seed the thoracic cavity or passing the needle through a chest wall abscess or otherwise infected tissue can result in empyema. 40. Question If a client continues to hypoventilate, the nurse will continually assess for a complication of: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis Correct Answer: A. Respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. The respiratory centers in the pons and medulla control alveolar ventilation. Chemoreceptors for PCO2, PO2, and pH regulate ventilation. Central chemoreceptors in the medulla are sensitive to changes in the pH level. A decreased pH level influences the mechanics of ventilation and maintains proper levels of carbon dioxide and oxygen. When ventilation is disrupted, arterial PCO2 increases and an acid-base disorder develops. Option B: In almost every scenario, respiratory alkalosis is induced by a process involving hyperventilation. These include central causes, hypoxemic causes, pulmonary causes, and iatrogenic causes. Central sources are a head injury, stroke, hyperthyroidism, anxiety-hyperventilation, pain, fear, stress, drugs, medications such as salicylates, and various toxins. Hypoxic stimulation leads to hyperventilation in an attempt to correct hypoxia at the expense of a CO2 loss. Option C: Hydrogen ion concentration is determined by acid ingestion, acid production, acid excretion, and renal and GI bicarbonate losses. Buffers such as bicarbonate minimize significant pH alterations. Further classification of metabolic acidosis is based on the presence or absence of an anion gap, or concentration of unmeasured serum anions. Option D: In general, the causes can be narrowed down to an intracellular shift of hydrogen ions, gastrointestinal (GI) loss of hydrogen ions, excessive renal hydrogen ion loss, retention or addition of bicarbonate ions, or volume contraction around a constant amount of extracellular bicarbonate known as contraction alkalosis. All of which leads to the net result of increased levels of bicarbonate in the blood. 41. Question A client is admitted to the hospital with acute bronchitis. While taking the client’s VS, the nurse notices he has an irregular pulse. The nurse understands that cardiac arrhythmias in chronic respiratory distress are usually the result of: A. Respiratory acidosis B. A build-up of carbon dioxide C. A build-up of oxygen without adequate expelling of carbon dioxide. D. An acute respiratory infection. Correct Answer: B. A build-up of carbon dioxide. The arrhythmias are caused by a build-up of carbon dioxide and not enough oxygen so that the heart is in a constant state of hypoxia. The majority of arrhythmias observed in these patients appeared to take the form of premature ventricular and/or supraventricular beats and less frequently of atrial fibrillation and/or attacks of supraventricular paroxysmal tachycardia. Cardiac rhythm alterations were observed using Holter monitoring in 70-90% of patients. No cardiac rhythm disorder is specific to this pathological condition. Option A: The compensation to respiratory acidosis consists in a secondary increase in bicarbonate concentration, and the arterial blood gas analysis is characterized by a reduced pH, increased pCO2 (initial variation), and increased bicarbonate levels (compensatory response). Option C: Acute bronchitis is a clinical diagnosis based on history, past medical history, lung exam, and other physical findings. Oxygen saturation plays an important role in judging the severity of the disease along with the pulse rate, temperature, and respiratory rate. Option D: Acute bronchitis is the result of acute inflammation of the bronchi secondary to various triggers, most commonly viral infection, allergens, pollutants, etc. Inflammation of the bronchial wall leads to mucosal thickening, epithelial-cell desquamation, and denudation of the basement membrane. At times, a viral upper respiratory infection can progress to infection of the lower respiratory tract resulting in acute bronchitis. 42. Question Auscultation of a client’s lungs reveals crackles in the left posterior base. The nursing intervention is to: A. Repeat auscultation after asking the client to deep breathe and cough. B. Instruct the client to limit fluid intake to less than 2000 ml/day. C. Inspect the client’s ankles and sacrum for the presence of edema. D. Place the client on bedrest in a semi-Fowler's position. Correct Answer: A. Repeat auscultation after asking the client to deep breathe and cough. Although crackles often indicate fluid in the alveoli, they may also be related to hypoventilation and will clear after a deep breath or a cough. Assess cough effectiveness and productivity. Coughing is the most effective way to remove secretions. Pneumonia may cause thick and tenacious secretions to patients. Option B: It is premature to impose fluid or activity restrictions. Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles. Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of the discomfort of moving chest wall and/or fluid in the lung due to a compensatory response to airway obstruction. Altered breathing patterns may occur together with use of accessory muscles to increase chest excursion to facilitate effective breathing. Option C: Inspection for edema would be appropriate after re-auscultation. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes. Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction. Option D: Elevate the head of bed, change position frequently. Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization, and expectoration of secretions. 43. Question The most reliable index to determine the respiratory status of a client is to: A. Observe the chest rising and falling.  B. Observe the skin and mucous membrane color. C. Listen and feel the air movement. D. Determine the presence of a femoral pulse. Correct Answer: C. Listen and feel the air movement. To check for breathing, the nurse places her ear and cheek next to the client’s mouth and nose to listen and feel for air movement. During the inspection, the examiner should pay attention to the pattern of breathing: thoracic breathing, thoracoabdominal breathing, coastal markings, and use of accessory breathing muscles. The use of accessory breathing muscles (i.e., scalenes, sternocleidomastoid muscle, intercostal muscles) could point to excessive breathing effort caused by pathologies. Option A: The chest rising and falling is not conclusive of a patent airway. The position of the patient should also be noted, patients with extreme pulmonary dysfunction will often sit up-right, and in distress, they assume the tripod position (leaning forward, resting their hands on their knees). Option B: Observing skin color is not an accurate assessment of respiratory status. The body habitus of the patient could provide information regarding chest compliance, especially in the case of severely obese patients where chest mobility and compliance are reduced due to added weight from adipose tissue. Option D: Checking the femoral pulse is not an assessment of respiratory status. Palpation should focus on detecting abnormalities like masses or bony crepitus. During palpation the examiner can evaluate tactile fremitus: the examiner will place both of his hands on the patient’s back, medial to the shoulder blades, and ask the patient to say “ninety-nine.” 44. Question A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the plan of care because of the polycythemia? A. Fluid volume deficit related to blood loss. B. Impaired tissue perfusion related to thrombosis. C. Activity intolerance related to dyspnea. D. Risk for infection related to suppressed immune response. Correct Answer: B. Impaired tissue perfusion related to thrombosis. Chronic hypoxia associated with COPD may stimulate excessive RBC production (polycythemia). This results in increased blood viscosity and the risk of thrombosis. The other nursing diagnoses are not applicable in this situation. The most common causes of secondary polycythemia include obstructive sleep apnea, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease (COPD). Option A: In secondary polycythemia, the number of red blood cells (RBCs) is increased as a result of an underlying condition. Secondary polycythemia would more accurately be called secondary erythrocytosis or erythrocythemia, as those terms specifically denote increased red blood cells. No blood loss is evident in the stem. Option C: Increased red blood cell mass increases blood viscosity and decreases tissue perfusion. With impaired circulation to the central nervous system, patients may present with headaches, lethargy, and confusion or more serious presentations, such as stroke and obtundation. Option D: Plethora manifests as increased redness of the skin and mucosal membranes. This finding is easier to detect on the palms or soles, where the skin is light in dark-skinned individuals. Some patients may have acrocyanosis caused by sluggish blood flow through small blood vessels. 45. Question The physician has scheduled a client for a left pneumonectomy. The position that will most likely be ordered postoperatively for his is the: A. Nonoperative side or back B. Operative side or back C. Back only D. Back or either side. Correct Answer: B. Operative side or back Following pneumonectomy, the client is positioned on the operative side to allow the fluid left in the lung space to consolidate and avoid the heart from shifting to the operative side. Pneumonectomy is defined as the surgical removal of the entire lung. Extrapleural pneumonectomy is an expanded procedure that also involves resection of parietal and visceral pleura, ipsilateral hemidiaphragm, pericardium, and mediastinal lymph nodes. Option A: The patient is then usually positioned in a lateral decubitus position with the operating side up. Proper positioning of the DLT or the bronchial blocker is usually reconfirmed with the FOB, and single lung ventilation is then started. Care should be taken to ensure proper positioning to avoid perioperative nerve injury. Option C: Following pneumonectomy, pulmonary functions decrease but are usually less than anticipated for removal of 50% of lung, especially for residual volume, and this may be explained by overexpansion of the remaining lung tissue. FEV1, FVC, DLCO, and lung compliance decrease. Airway resistance increases. Option D: Patients with no disease in the remaining lung usually do have normal SaO2, PO2, and PaCO2 at rest. A chest X-ray immediately following pneumonectomy usually shows the trachea in the midline and the postpneumonectomy space to be filled with air. Later, that space becomes filled gradually with fluid at a rate of 1 to 2 intercostal spaces/day. The ipsilateral diaphragm becomes elevated, and the mediastinum is gradually shifted towards the operative side. 46. Question Assessing a client who has developed atelectasis postoperatively, the nurse will most likely find: A. A flushed face. B. Dyspnea and pain. C. Decreased temperature. D. Severe cough and no pain. Correct Answer: B. Dyspnea and pain Atelectasis is a collapse of the alveoli due to obstruction or hypoventilation. Clients become short of breath, have a high temperature, and usually experience severe pain but do not have a severe cough. The shortness of breath is a result of decreased oxygen-carbon dioxide exchange at the alveolar level. Postoperative atelectasis typically occurs within 72 hours of general anesthesia and is a well-known postoperative complication. Option A: The definition of atelectasis is a partial collapse of the lung. It can cause people to feel short of breath. It can be a consequence of several different processes, most commonly when there is a poor inspiratory effort, an obstruction blocking airflow into the lung, extra pressure exerted on the outside of the lung, or deficient production or function of a specific protein in the lung. Option C: Postoperative fever has historically been attributed to atelectasis, but there is no evidence supporting the finding that atelectasis is a causative mechanism for fever. For patients with atelectasis, the prognosis varies greatly, and the primary determination is the underlying etiology and patient co-morbidities. Option D: Inadequate pain control can contribute to the development of atelectasis by inducing shallow breathing (“splinting”) and/or inhibiting coughing. Typically, atelectasis is asymptomatic. However, a patient might also present with decreased or absent breath sounds, crackles, cough, sputum production, dyspnea, tachypnea, and/or diminished chest expansion. 47. Question A fifty-year-old client has a tracheostomy and requires tracheal suctioning. The first intervention in completing this procedure would be to: A. Change the tracheostomy dressing. B. Provide humidity with a trach mask. C. Apply oral or nasal suction. D. Deflate the tracheal cuff. Correct Answer: C. Apply oral or nasal suction. Before d