1. 1. Question 2. 2.

Question

An elderly client with pneumonia may appear with which of the following symptoms first? Which of the following pathophysiological mechanisms that occur in the lung parenchyma
allows pneumonia to develop?
o A. Altered mental status and dehydration
o A. Atelectasis
o B. Fever and chills
o B. Bronchiectasis
o C. Hemoptysis and dyspnea
o C. Effusion
o D. Pleuritic chest pain and cough
o D. Inflammation
Incorrect
Correct
Correct Answer: A. Altered mental status and dehydration
Correct Answer: D. Inflammation
Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common symptoms
of pneumonia, but elderly clients may first appear with only an altered mental status and The most common feature of all types of pneumonia is an inflammatory pulmonary response
dehydration due to a blunted immune response. Pneumonia is a common cause of mortality to the offending organism or agent. The resident macrophages serve to protect the lung from
and morbidity. It can have a myriad of clinical presentations and can pose a diagnostic dilemma foreign pathogens. Ironically, the inflammatory reaction triggered by these very macrophages
especially in the setting of severely ill patients with several comorbidities and underlying lung is what is responsible for the histopathological and clinical findings seen in pneumonia.
pathologies.
• Option A: Atelectasis indicates a collapse of a portion of the airway that
• Option B: Historically, the chief complaints in case of pneumonia include doesn’t occur with pneumonia. It is caused by the partial or complete,
systemic signs like fever with chills, malaise, loss of appetite, and myalgias. reversible collapse of the small airways resulting in an impaired exchange of
These findings are more common in viral pneumonia as compared to bacterial CO2 and O2 – i.e., intrapulmonary shunt. The incidence of atelectasis in
pneumonia. patients undergoing general anesthesia is 90%.

• Option C: Pulmonary findings include cough with or without sputum • Option B: Bronchiectasis is a chronic lung disease characterized by persistent
production. Bacterial pneumonia is associated with purulent or rarely blood- and lifelong widening of the bronchial airways and weakening of the function
tinged sputum. Viral pneumonia is associated with watery or occasionally mucociliary transport mechanism owing to repeated infection contributing to
mucopurulent sputum production. bacterial invasion and mucus pooling throughout the bronchial tree.

• Option D: There may be an associated pleuritic chest pain with the • Option C: An effusion is an accumulation of excess pleural fluid in the pleural
concomitant involvement of the pleura. Dyspnea and a diffuse heaviness of space, which may be a secondary response to pneumonia. Accumulation of
the chest are also seen occasionally. Complications of untreated or under- excess fluid can occur if there is excessive production or decreased absorption
treated pneumonia include respiratory failure, sepsis, metastatic infections, or both overwhelming the normal homeostatic mechanism. If pleural effusion
empyema, lung abscess, and multi-organ dysfunction. is mainly due to mechanisms that lead to pleural effusion mainly due to
increased hydrostatic pressure are usually transudative, and leading to pleural
effusion have altered the balance between hydrostatic and oncotic pressures
 (usually transudates), increased mesothelial and capillary permeability • Option D: Most patients present with very nonspecific symptoms of chronic
(usually exudates) or impaired lymphatic drainage. shortness of breath and cough with or without sputum production. As the
disease process advances, the shortness of breath and cough progressively
3. 3. Question
gets worse. Initially, there is exertional dyspnea with significant physical
A 7-year-old client is brought to the E.R. He’s tachypneic and afebrile and has a respiratory activity, especially arm work at or above shoulder level with progression to
rate of 36 breaths/minute and a nonproductive cough. He recently had a cold. From his history, dyspnea with simple daily activities and even at rest. Some patients may
the client may have which of the following? present with wheezing because of the airflow obstruction.

o A. Acute asthma 4. 4. Question

o B. Bronchial pneumonia Which of the following assessment findings would help confirm a diagnosis of asthma in a client
suspected of having the disorder?
o C. Chronic obstructive pulmonary disease (COPD)
o A. Circumoral cyanosis
o D. Emphysema
o B. Increased forced expiratory volume
Incorrect
o C. Inspiratory and expiratory wheezing
Correct Answer: A. Acute asthma
o D. Normal breath sounds
Based on the client’s history and symptoms, acute asthma is the most likely diagnosis. Patients
will usually give a history of a wheeze or a cough, exacerbated by allergies, exercise, and cold. Incorrect
There is often diurnal variation, with symptoms being worse at night. Many asthmatics have
Correct Answer: C. Inspiratory and expiratory wheezing
nocturnal coughing spells but appear normal in the daytime. He’s unlikely to have bronchial
pneumonia without a productive cough and fever and he’s too young to have developed COPD Inspiratory and expiratory wheezes are typical findings in asthma. Patients will show some
or emphysema. respiratory distress, often sitting forward to splint open their airways. On auscultation, a
bilateral, expiratory wheeze will be heard. In life-threatening asthma, the chest may be silent,
• Option B: Recurrent episodes of acute shortness of breath, typically occurring as air cannot enter or leave the lungs, and there may be signs of systemic hypoxia.
at night or in the early morning hours, are the cardinal manifestation of
bronchial asthma. Further symptoms include cough, wheezing, and a feeling • Option A: Circumoral cyanosis may be present in extreme cases of
of tightness in the chest. Auscultation of the chest reveals rales, rhonchi, and respiratory distress. In many cases, circumoral cyanosis is considered a type
wheezes. of acrocyanosis. Acrocyanosis happens when small blood vessels shrink in
response to cold. In older children, circumoral cyanosis often appears when
• Option C: It is associated with structural lung changes due to chronic they go outside in cold weather or get out of a warm bath. This type of cyanosis
inflammation from prolonged exposure to noxious particles or gases most should go away once they warm up. If it doesn’t, seek emergency medical
commonly cigarette smoke. Chronic inflammation causes airway narrowing treatment. Circumoral cyanosis that doesn’t go away with heat could be a sign
and decreased lung recoil. Patients usually present with complaints of chronic of a serious lung or heart problem, such as cyanotic congenital heart disease.
and progressive dyspnea, cough, and sputum production. Patients may also
have wheezing and chest tightness. • Option B: The nurse would expect the client to have a decreased forced
expiratory volume because asthma is an obstructive pulmonary disease. Peak
 expiratory flow measurement is common today and allows one to document though the outcomes are sometimes not consistent. Anxiety and depression
response to therapy. A limitation of this test is that it is effort-dependent. may be associated with poor asthma control.
Spirometry should be done before treatment to determine the severity of the
disorder. A reduced ratio of FEV1 to FVC is indicative of airway obstruction, • Option B: Extrinsic asthma is caused by dust, molds, and pets; easily
which is reversible with treatment. identifiable allergens. Extrinsic asthma is simply asthma caused by an allergic
reaction, especially a chronic one. If the asthma is allergic, the client will have
• Option D: Breath sounds will be “tight” sounding or markedly decreased; they higher levels of IgE (Immunoglobulin E) present in the blood test.
won’t be normal. Asthma is a condition mediated by inflammation. The
resulting physiologic response in the airways is bronchoconstriction and • Option D: Mediated asthma doesn’t exist. When airflow is obstructed as a
airway edema. This response is triggered by an irritant, allergen, or infection. result of exercise, it’s known as exercise-induced bronchoconstriction (EIB),
As air moves through these narrowed airways, the primary lung sound is high- which is a subcategory of asthma. EIB was previously known as exercise-
pitched wheeze. induced asthma; however, exercise-induced asthma incorrectly implies that
exercise is the underlying cause of asthma when it is actually its trigger, not
5. 5. Question the cause.
Which of the following types of asthma involves an acute asthma attack brought on by an upper 6. 6. Question
respiratory infection?
A client with acute asthma showing inspiratory and expiratory wheezes and a decreased
o A. Emotional expiratory volume should be treated with which of the following classes of medication right
away?
o B. Extrinsic
o A. Beta-adrenergic blockers
o C. Intrinsic
o B. Bronchodilators
o D. Mediated
o C. Inhaled steroids
Correct
o D. Oral steroids
Correct Answer: C. Intrinsic
Incorrect
Intrinsic asthma doesn’t have an easily identifiable allergen and can be triggered by the
common cold. In intrinsic asthma, IgE is usually only involved locally, within the airway Correct Answer: B. Bronchodilators
passages. Unlike extrinsic asthma, which is triggered by commonly known allergens, intrinsic
asthma may be triggered by a wide range of non-allergy-related factors. Unlike people with Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the
extrinsic asthma, those with intrinsic asthma usually have a negative allergy skin test, so they cause of reduced airflow. Bronchodilators are indicated for individuals that have lower than
often won’t benefit from allergy shots or allergy medications. optimal airflow through the lungs. The mainstay of treatment is beta-2 agonists that target the
smooth muscles in the bronchioles of the lung. Various respiratory conditions may require
• Option A: Asthma caused by emotional reasons is considered to be in the bronchodilators, including asthma and chronic obstructive pulmonary disease.
extrinsic category. Strong emotions and stress are well-known triggers of
asthma. There is evidence of a link between asthma, anxiety, and depression, • Option A: Beta-adrenergic blockers aren’t used to treat asthma and can cause
bronchoconstriction. The catecholamines, epinephrine, and norepinephrine
 bind to B1 receptors and increase cardiac automaticity as well as conduction antagonists (salbutamol and ipratropium bromide respectively) and anti-inflammatories such
velocity. B1 receptors also induce renin release, and this leads to an increase as inhaled steroids (usually beclomethasone but steroids via any route will be helpful).
in blood pressure. In contrast, binding to B2 receptors causes relaxation of the
smooth muscles along with increased metabolic effects such as • Option A: First, resolve the acute phase of the attack and how to prevent
glycogenolysis. attacks in the future. During an acute exacerbation, there may be a fine tremor
in the hands due to salbutamol use, and mild tachycardia. Patients will show
• Option C: Inhaled steroids may be given to reduce the inflammation but aren’t some respiratory distress, often sitting forward to splint open their airways.
used for emergency relief. Inhaled corticosteroids have potent glucocorticoid
activity and work directly at the cellular level by reversing capillary permeability • Option C: It may not be necessary to place the client on a cardiac monitor
and lysosomal stabilization to reduce inflammation. The onset of action is because he’s only 19-years-old unless he has a past medical history of cardiac
gradual and may take anywhere from several days to several weeks for problems. On auscultation, a bilateral, expiratory wheeze will be heard. In life-
maximal benefit with consistent use. threatening asthma, the chest may be silent, as air cannot enter or leave the
lungs, and there may be signs of systemic hypoxia.
• Option D: Corticosteroids produce their effect through multiple pathways. In
general, they produce anti-inflammatory and immunosuppressive effects, • Option D: Measures to take include calming the patient to get them to relax,
protein and carbohydrate metabolic effects, water and electrolyte effects, moving outside or away from the likely source of allergen, and cooling the
central nervous system effects, and blood cell effects. Oral administration is person. Removing clothing and washing the face and mouth to remove
more common for chronic treatment. Patients should receive non-systemic allergens is sometimes done, but it is not evidence-based.
therapy whenever possible, to minimize systemic exposure. 8. 8. Question
7. 7. Question A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day has
A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on
44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following this information, he most likely has which of the following conditions?
actions should be taken first? o A. Adult respiratory distress syndrome (ARDS)
o A. Take a full medication history. o B. Asthma
o B. Give a bronchodilator by nebulizer. o C. Chronic obstructive bronchitis
o C. Apply a cardiac monitor to the client. o D. Emphysema
o D. Provide emotional support to the client. Incorrect
Incorrect Correct Answer: C. Chronic obstructive bronchitis
Correct Answer: B. Give a bronchodilator by nebulizer. Because of his extensive smoking history and symptoms, the client most likely has chronic
The client is having an acute asthma attack and needs to increase oxygen delivery to the lung obstructive bronchitis. Chronic bronchitis is a type of chronic obstructive pulmonary disease
and body. Nebulized bronchodilators open airways and increase the amount of oxygen (COPD) that is defined as a productive cough of more than 3 months occurring within a span
delivered. Medical management includes bronchodilators like beta-2 agonists and muscarinic
of 2 years. Patients typically present with chronic productive cough, malaise, and symptoms of Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and
excessive coughing such as chest or abdominal pain. peripheral edema, cyanotic nail beds, and, at times, circumoral cyanosis. People with chronic
bronchitis are sometimes called “blue bloaters” because of their bluish-colored skin and lips.
• Option A: Clients with ARDS have acute symptoms of and typically need large Blue bloaters often take deeper breaths but can’t take in the right amount of oxygen.
amounts of oxygen. Acute respiratory distress syndrome (ARDS) is a life-
threatening condition characterized by poor oxygenation and non-compliant or • Option A: Clients with ARDS are acutely short of breath and frequently need
“stiff” lungs. The disorder is associated with capillary endothelial injury and intubation for mechanical ventilation and large amounts of oxygen. Clients with
diffuse alveolar damage. Once ARDS develops, patients usually have varying ARDS have acute symptoms and typically need large amounts of oxygen.
degrees of pulmonary artery vasoconstriction and may subsequently develop Acute respiratory distress syndrome (ARDS) is a life-threatening condition
pulmonary hypertension. characterized by poor oxygenation and non-compliant or “stiff” lungs. The
disorder is associated with capillary endothelial injury and diffuse alveolar
• Option B: Clients with asthma tend not to have a chronic cough or peripheral damage. Once ARDS develops, patients usually have varying degrees of
edema. Asthma is a common disease and has a range of severity, from a very pulmonary artery vasoconstriction and may subsequently develop pulmonary
mild, occasional wheeze to acute, life-threatening airway closure. It usually hypertension.
presents in childhood and is associated with other features of atopy, such as
eczema and hayfever. Asthma is a condition of acute, fully reversible airway • Option B: Clients with asthma don’t exhibit characteristics of chronic disease.
inflammation, often following exposure to an environmental trigger. Asthma is a common disease and has a range of severity, from a very mild,
occasional wheeze to acute, life-threatening airway closure. It usually presents
• Option D: Most patients present with very nonspecific symptoms of chronic in childhood and is associated with other features of atopy, such as eczema
shortness of breath and cough with or without sputum production. As the and hayfever. Asthma is a condition of acute, fully reversible airway
disease process advances, the shortness of breath and cough progressively inflammation, often following exposure to an environmental trigger.
gets worse. Initially, there is exertional dyspnea with significant physical
activity, especially arm work at or above shoulder level with progression to • Option D: Clients with emphysema appear pink and cachectic (a state of ill
dyspnea with simple daily activities and even at rest. Some patients may health, malnutrition, and wasting). Emphysema comes on very gradually and
present with wheezing because of the airflow obstruction. is irreversible. People with emphysema are sometimes called “pink puffers”
because they have difficulty catching their breath and their faces redden while
9. 9. Question gasping for air.
The term “blue bloater” refers to which of the following conditions? 10. 10. Question
o A. Adult respiratory distress syndrome (ARDS) The term “pink puffer” refers to the client with which of the following conditions?
o B. Asthma o A. ARDS
o C. Chronic obstructive bronchitis o B. Asthma
o D. Emphysema o C. Chronic obstructive bronchitis
Incorrect o D. Emphysema
Correct Answer: C. Chronic obstructive bronchitis Correct
Correct Answer: D. Emphysema A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to
breathe. He’s tachypneic, with a prolonged expiratory phase. He has no cough. He leans
Because of the large amount of energy it takes to breathe, clients with emphysema are usually forward with his arms braced on his knees to support his chest and shoulders for breathing.
cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer”. This client has symptoms of which of the following respiratory disorders?
Emphysema comes on very gradually and is irreversible. People with emphysema are
sometimes called “pink puffers” because they have difficulty catching their breath and their o A. ARDS
faces redden while gasping for air.
o B. Asthma
• Option A: Clients with ARDS are usually acutely short of breath. Clients with
o C. Chronic obstructive bronchitis
ARDS have acute symptoms of and typically need large amounts of oxygen.
Acute respiratory distress syndrome (ARDS) is a life-threatening condition o D. Emphysema
characterized by poor oxygenation and non-compliant or “stiff” lungs. The
disorder is associated with capillary endothelial injury and diffuse alveolar Incorrect
damage. Once ARDS develops, patients usually have varying degrees of
Correct Answer: D. Emphysema
pulmonary artery vasoconstriction and may subsequently develop pulmonary
hypertension. These are classic signs and symptoms of a client with emphysema. In the early stages of the
disease, the physical examination may be normal. Patients with emphysema are typically
• Option B: Clients with asthma don’t have any particular characteristics.
referred to as “pink puffers,” meaning cachectic and non-cyanotic. Expiration through pursed
Asthma is a common disease and has a range of severity, from a very mild,
lips increases airway pressure and prevents airway collapse during respiration, and the use of
occasional wheeze to acute, life-threatening airway closure. It usually presents
accessory muscles of respiration indicates advanced disease.
in childhood and is associated with other features of atopy, such as eczema
and hayfever. Asthma is a condition of acute, fully reversible airway • Option A: Clients with ARDS are acutely short of breath and require
inflammation, often following exposure to an environmental trigger. emergency care. The physical examination will include findings associated
with the respiratory system, such as tachypnea and increased effort to breathe.
• Option C: Clients with chronic obstructive bronchitis are bloated and cyanotic
Systemic signs may also be evident depending on the severity of illness, such
in appearance. Clients with chronic obstructive bronchitis appear bloated; they
as central or peripheral cyanosis resulting from hypoxemia, tachycardia, and
have large barrel chests and peripheral edema, cyanotic nail beds, and, at
altered mental status. Despite 100% oxygen, patients have low oxygen
times, circumoral cyanosis. People with chronic bronchitis are sometimes
saturation.
called “blue bloaters” because of their bluish-colored skin and lips. Blue
bloaters often take deeper breaths but can’t take in the right amount of oxygen. • Option B: Those with asthma are also acutely short of breath during an attack
and appear very frightened. Patients will usually give a history of a wheeze or
a cough, exacerbated by allergies, exercise, and cold. There is often diurnal
variation, with symptoms being worse at night. There may be some mild chest
pain associated with acute exacerbations. Many asthmatics have nocturnal
coughing spells but appear normal in the daytime.

• Option C: Clients with chronic obstructive bronchitis are bloated and cyanotic
11. 11. Question in appearance. The most common symptom of patients with chronic bronchitis
is a cough. The history of a cough typical of chronic bronchitis is characterized
 to be present for most days in a month lasting for 3 months with at least 2 such • Option B: The vaccines have no effect on bronchodilation or respiratory care.
episodes occurring for 2 years in a row. A productive cough with sputum is Both vaccines promote active immunization against the serotypes of the
present in about 50% of patients. conjugate and capsular polysaccharides contained in the formulation of the
vaccine. Immunity develops approximately 2 to 3 weeks after vaccination and
12. 12. Question
lasts for five years. In children and the elderly, re-immunization may be
It’s highly recommended that clients with asthma, chronic bronchitis, and emphysema have necessary sooner.
Pneumovax and flu vaccinations for which of the following reasons?
• Option C: Studies done on animals have not shown fetal adverse effects or
o A. All clients are recommended to have these vaccines. increased risk to the fetus. It is unknown if the vaccine is excreted with breast
milk. Caution is necessary when administering this vaccine to breastfeeding
o B. These vaccines produce bronchodilation and improve oxygenation. women. There is no overdose risk with the administration of the vaccine.
o C. These vaccines help reduce the tachypnea these clients experience. 13. 13. Question
o D. Respiratory infections can cause severe hypoxia and possibly death Exercise has which of the following effects on clients with asthma, chronic bronchitis, and
in these clients. emphysema?
Correct o A. It enhances cardiovascular fitness.
Correct Answer: D. Respiratory infections can cause severe hypoxia and possibly death o B. It improves respiratory muscle strength.
in these clients.
o C. It reduces the number of acute attacks.
It’s highly recommended that clients with respiratory disorders be given vaccines to protect
against respiratory infection. Infections can cause these clients to need intubation and o D. It worsens respiratory function and is discouraged.
mechanical ventilation, and it may be difficult to wean these clients from the ventilator. Another
Incorrect
pneumococcal vaccine, PPSV23, is indicated in the United States for all adults 65 years of age
and older, as well as younger patients with conditions that increase the risk for developing Correct Answer: A. It enhances cardiovascular fitness.
pneumococcal pneumonia or invasive pneumococcal disease. Conditions that would indicate
PPSV23 in patients younger than 65 years of age are as follows: chronic heart disease Exercise can improve cardiovascular fitness and help the client tolerate periods of hypoxia
excluding hypertension, chronic lung disease including asthma, diabetes mellitus, better, perhaps reducing the risk of heart attack. People with long-term lung conditions can help
cerebrospinal fluid leak, cochlear implant, alcohol use disorder, chronic liver disease, cigarette improve their symptoms through regular exercise. It can be tempting to avoid exercise because
smoking, hemoglobinopathy (including sickle cell disease), etc. one may think it will make them breathless, but if the client does less activity he becomes less
fit, and daily activities will become even harder.
• Option A: Recommendations are that all patients who received PPSV23
before the age of 65 years be revaccinated at age 65 unless the vaccine is • Option B: Most exercise has little effect on respiratory muscle strength, and
given less than ten years before the patient turns 65 years old, in which case these clients can’t tolerate the type of exercise necessary to do this.
patients should be revaccinated ten years following the first dose. Intermittent exercises can help deal with shortness of breath. In this case, the
Recommendations are that patients with functional or anatomic asplenia or client alternates brief exercise, lasting 1–2 minutes, with moments of rest (or
immunocompromised individuals receive repeat doses of the vaccination slower exercise). This is called interval training.
every ten years after the first dose.
 • Option C: Exercise won’t reduce the number of acute attacks. Having asthma by decreasing preload to the heart and they can also reduce pulmonary
should not restrict the ability to exercise or be physically active. If the client edema. The presence of pulmonary hypertension in COPD is associated with
feels uncomfortable during or after exercise, he should ask his doctor to increased mortality risk 6 and symptoms related to excessive fluid overload
investigate whether the management of his condition could be improved. In may lead an individual with COPD to present to hospital for acute care
fact, many athletes have asthma and are able to compete at the highest level
when their condition is well-controlled. • Option C: Diuretic drugs may theoretically improve respiratory health
outcomes among individuals with chronic obstructive pulmonary disease
• Option D: In some instances, exercise may be contraindicated, and the client (COPD), but they may also contribute to respiratory harm. There are minimal
should check with his physician before starting any exercise program. It is best and conflicting data regarding the potential respiratory effects of systemic
to ask the guidance of a doctor or physiotherapist before one begins diuretic drugs among individuals with COPD.
exercising, to ensure that the exercise plans are in line with the body’s capacity
and are safe. All exercise programs must be built up over time to allow the • Option D: Reducing fluid volume won’t improve respiratory function but may
body to adapt. improve oxygenation. Acetazolamide inhibits the renal carbonic anhydrase
enzyme, which reduces serum bicarbonate and contributes to metabolic
14. 14. Question acidosis, which in turn increases minute ventilation through peripheral and
central chemoreceptor stimulation. By stimulating minute ventilation and
Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following improving gas exchange, acetazolamide may mitigate dyspnoea crises and
reasons best explains why? respiratory exacerbations among individuals with COPD.
o A. Reducing fluid volume reduces oxygen demand. 15. 15. Question
o B. Reducing fluid volume improves clients’ mobility. A 69-year-old client appears thin and cachectic. He’s short of breath at rest and his dyspnea
o C. Restricting fluid volume reduces sputum production. increases with the slightest exertion. His breath sounds are diminished even with deep
inspiration. These signs and symptoms fit which of the following conditions?
o D. Reducing fluid volume improves respiratory function.
o A. ARDS
Incorrect
o B. Asthma
Correct Answer: A. Reducing fluid volume reduces oxygen demand.
o C. Chronic obstructive bronchitis
Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand and,
in turn, reduces the respiratory rate. It may also reduce edema and improve mobility a little, but o D. Emphysema
exercise tolerance will still be harder to clear airways. As a result, diuretic drugs may be Correct
prescribed in COPD for a variety of reasons: pulmonary hypertension and cor pulmonale;
pulmonary edema; systemic hypertension; and empirically for severe dyspnoea refractory to Correct Answer: D. Emphysema
maximal conventional therapy.
In emphysema, the wall integrity of the individual air sacs is damaged, reducing the surface
• Option B: Diuretic drugs may theoretically improve respiratory health area available for gas exchange. Very little air movement occurs in the lungs because of
outcomes in COPD through several possible mechanisms. Diuretics may bronchial collapse, as well. In the early stages of the disease, the physical examination may
reduce pulmonary hypertension (either subclinical or overt) and cor pulmonale be normal. Patients with emphysema are typically referred to as “pink puffers,” meaning
cachectic and non-cyanotic. Expiration through pursed lips increases airway pressure and Correct
prevents airway collapse during respiration, and the use of accessory muscles of respiration
indicates advanced disease. Correct Answer: C. The client breathes only when his oxygen levels dip below a certain
point.
• Option A: In ARDS, the client’s condition is more acute and typically requires
Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known
mechanical ventilation. Clients with ARDS are acutely short of breath and
as the hypoxic drive. In the meantime, his carbon dioxide levels continue to climb, and the client
require emergency care. The physical examination will include findings
will pass out, leading to a respiratory arrest. The hypoxic drive theory then goes on to say that
associated with the respiratory system, such as tachypnea and increased
if the healthcare provider gives these patients too much oxygen they blunt their hypoxic drive.
effort to breathe. Systemic signs may also be evident depending on the
As their chemoreceptors are already tolerant of high levels of carbon dioxide, and therefore
severity of illness, such as central or peripheral cyanosis resulting from
they have also lost that drive, their respirations will begin to slow causing a further rise in carbon
hypoxemia, tachycardia, and altered mental status. Despite 100% oxygen,
dioxide levels, and a consequent acidosis.
patients have low oxygen saturation.
• Option A: They don’t take a breath when their levels of carbon dioxide are
• Option B: In asthma, wheezing is prevalent. Patients will usually give a history
higher than normal, as do those with healthy respiratory physiology. COPD
of a wheeze or a cough, exacerbated by allergies, exercise, and cold. There
patients tend to have chronically elevated levels of carbon dioxide due to the
is often diurnal variation, with symptoms being worse at night. There may be
nature of their illness. The theory goes then that because of this chronically
some mild chest pain associated with acute exacerbations. Many asthmatics
elevated level of carbon dioxide in the chemoreceptors become tolerant of
have nocturnal coughing spells but appear normal in the daytime.
these high levels and therefore the carbon dioxide ceases to be that person’s
• Option C: The most common symptom of patients with chronic bronchitis is a drive to breathe. What therefore drives them to breathe is the hypoxic drive or
cough. The history of a cough typical of chronic bronchitis is characterized to the lower levels of oxygen.
be present for most days in a month lasting for 3 months with at least 2 such
• Option B: If too much oxygen is given, the client has little stimulus to take
episodes occurring for 2 years in a row. A productive cough with sputum is
another breath. The peripheral chemoreceptors are sensitive to the levels of
present in about 50% of patients.
oxygen in the body. They will send a signal to breathe when the partial
16. 16. Question pressure of oxygen begins to fall. This is referred to as the hypoxic drive but
this drive has a much more minor role in breathing.
A client with emphysema should receive only 1 to 3 L/minute of oxygen if needed, or he may
lose his hypoxic drive. Which of the following statements is correct about hypoxic drive? • Option D: The central chemoreceptors monitor carbon dioxide levels in the
body. When those carbon dioxide levels are high a signal is sent to speed up
o A. The client doesn’t notice he needs to breathe. the drive to breathe to blow off the excess carbon dioxide. So the levels of
o B. The client breathes only when his oxygen levels climb above a certain carbon dioxide dictate how fast we will breathe.
point.

o C. The client breathes only when his oxygen levels dip below a certain
point.

o D. The client breathes only when his carbon dioxide level dips below a certain
point.
 17. 17. Question • Option C: If the client has signs and symptoms of an infection, he should
contact his physician at once. Moderate and severe exacerbations are defined
Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which
by the presence of 2 or all 3 of the symptoms respectively. Patients may have
of the following topics?
acute respiratory failure and physical findings of hypoxemia and hypercapnia.
o A. How to have his wife learn to listen to his lungs with a stethoscope from Arterial blood gas analysis, chest imaging, and pulse oximetry are indicated.
Wal-Mart.
18. 18. Question
o B. How to increase his oxygen therapy.
Which of the following respiratory disorders is most common in the first 24 to 48 hours after
o C. How to treat respiratory infections without going to the physician. surgery?

o D. How to recognize the signs of an impending respiratory infection. o A. Atelectasis

Incorrect o B. Bronchitis

Correct Answer: D. How to recognize the signs of an impending respiratory infection. o C. Pneumonia

Respiratory infection in clients with a respiratory disorder can be fatal. It’s important that the o D. Pneumothorax
client understands how to recognize the signs and symptoms of an impending respiratory
Incorrect
infection. Acute exacerbation of COPD is an acute worsening of respiratory symptoms.
Assessing severity is often based on the model developed by Anthonisen and colleagues which Correct Answer: A. Atelectasis
classifies severity by the presence of worsening dyspnea, sputum volume, and purulence. Mild
exacerbations are defined by the presence of 1 of these symptoms in addition to one of the Atelectasis develops when there’s interference with the normal negative pressure that
following: increased wheezing, increased cough, fever without another cause, upper promotes lung expansion. Clients in the postoperative phase often splint their breathing
respiratory infection within 5 days, or an increase in heart rate or respiratory rate from the because of pain and positioning, which causes hypoxia. Postoperative atelectasis typically
patient’s baseline. occurs within 72 hours of general anesthesia and is a well-known postoperative complication.
The decrease in pressure allows for passive movement of air into the lungs. This process is
• Option A: It isn’t appropriate for the wife to listen to his lung sounds, besides, inhibited by general anesthesia due to diaphragm relaxation. Patients lying supine have
you can’t purchase stethoscopes from Wal-Mart. COPD will typically present cephalad displacement of the diaphragm further decreasing the transmural pressure gradient
in adulthood and often during the winter months. Patients usually present with and increasing the likelihood of atelectasis. It’s uncommon for any of the other respiratory
complaints of chronic and progressive dyspnea, cough, and sputum disorders to develop.
production. Patients may also have wheezing and chest tightness.
• Option B: Acute bronchitis is caused by infection of the large airways
• Option B: Hospitalized patients often require oxygen and bronchodilator commonly due to viruses and is usually self-limiting. Bacterial infection is
therapy in the form of a SABA with or without a SAMA. Oxygen therapy can uncommon. Approximately 95% of acute bronchitis in healthy adults is
range from a nasal cannula to mechanical ventilation depending on the secondary to viruses. It can sometimes be caused by allergens, irritants, and
severity of the exacerbation. Pulmonary rehabilitation plays a large role in bacteria. Irritants include smoke inhalation, polluted air inhalation, dust, among
improving outcomes. Rehabilitation has been shown to improve the quality of others.
life, dyspnea, and exercise capacity in patients with COPD.
 • Option C: While identifying an etiologic agent for pneumonia is essential for chest (postural drainage). This allows mucus to drain better from the bottom
effective treatment as well as epidemiological record keeping, this is seldom of the lungs.
seen in clinical practice. Widespread reviews have shown that a single cause
of pneumonia has often been identified in less than 10% of patients presenting • Option B: Reducing oxygen requirements doesn’t affect the development of
to the emergency department. atelectasis. Removal of airway obstructions may be done by suctioning mucus
or by bronchoscopy. During bronchoscopy, the doctor gently guides a flexible
• Option D: A pneumothorax is defined as a collection of air outside the lung tube down the throat to clear the airways.
but within the pleural cavity. It occurs when air accumulates between the
parietal and visceral pleura inside the chest. The air accumulation can apply • Option C: Placing someone on mechanical ventilation doesn’t improve
pressure on the lung and make it collapse. The degree of collapse determines atelectasis. Continuous positive airway pressure (CPAP) may be helpful in
the clinical presentation of pneumothorax. Air can enter the pleural space by some people who are too weak to cough and have low oxygen levels
two mechanisms, either by trauma causing a communication through the chest (hypoxemia) after surgery.
wall or from the lung by rupture of visceral pleura. 20. 20. Question
19. 19. Question Emergency treatment of a client in status asthmaticus includes which of the following
Which of the following measures can reduce or prevent the incidence of atelectasis in a medications?
postoperative client? o A. Inhaled beta-adrenergic agents
o A. Chest physiotherapy o B. Inhaled corticosteroids
o B. Mechanical ventilation o C. I.V. beta-adrenergic agents
o C. Reducing oxygen requirements o D. Oral corticosteroids
o D. Use of an incentive spirometer. Incorrect
Incorrect Correct Answer: A. Inhaled beta-adrenergic agents
Correct Answer: D. Use of an incentive spirometer. Inhaled beta-adrenergic agents help promote bronchodilation, which improves oxygenation.
Using an incentive spirometer requires the client to take deep breaths and promotes lung Albuterol is preferred over metaproterenol in that class because of its higher beta 2 selectivities
expansion. Incentive spirometry is designed to mimic natural sighing or yawning by and longer duration of action. The dose-response curve and duration of action of these
encouraging the patient to take long, slow, deep breaths. This decreases pleural pressure, medications are adversely affected by a combination of patient factors, including pre-existing
promoting increased lung expansion and better gas exchange. When the procedure is repeated bronchoconstriction, airway inflammation, mucus plugging, poor patient effort, and
on a regular basis, atelectasis may be prevented or reversed. coordination.

• Option A: Chest physiotherapy helps mobilize secretions but won’t prevent • Option B: Inhaled corticosteroids have potent glucocorticoid activity and work
atelectasis. Techniques that help the client breathe deeply after surgery to re- directly at the cellular level by reversing capillary permeability and lysosomal
expand collapsed lung tissue are very important. These techniques are best stabilization to reduce inflammation. The onset of action is gradual and may
learned before surgery. Positioning the body so that the head is lower than the take anywhere from several days to several weeks for maximal benefit with
 consistent use. Metabolism is through the hepatic route, with a half-life mostly with clear airways, slow-onset exacerbation patients have extensive
elimination of up to 24 hours. airway inflammation and mucus plugging.

• Option C: I.V. beta-adrenergic agents can be used but have to be monitored • Option C: Status asthmaticus can be prevented if triggers and stress factors
because of their greater systemic effects. They’re typically used when the are avoided, and compliance with the medicines is good. Identify those
inhaled beta-adrenergic agents don’t work. Intravenous beta-agonists are not individuals who are at a greater risk of exacerbation, such as extremes of ages.
routinely recommended, although there are reports of center-specific use in Environmental management is essential in patients with environmental
younger patients with status asthmaticus, nonresponsive to inhaled therapy allergies. Inpatient education by trained lay people resulted in improvement in
demonstrating persistent severe hyperinflation of airways. compliance with inhaler management and post-discharge care.

• Option D: Corticosteroids are slow-acting, so their use won’t reduce hypoxia • Option D: Typically, secretions aren’t a problem in status asthmaticus.
in the acute phase. At a physiologic level, steroids reduce airway inflammation Albuterol is preferred over metaproterenol in that class because of its higher
and mucus production and potentiate beta-agonist activity in smooth muscles beta 2 selectivities and longer duration of action. The dose-response curve
and reduce beta-agonists tachyphylaxis in patients with severe asthma. and duration of action of these medications are adversely affected by a
combination of patient factors, including pre-existing bronchoconstriction,
21. 21. Question airway inflammation, mucus plugging, poor patient effort, and coordination.
Which of the following treatment goals is best for the client with status asthmaticus? 22. 22. Question
o A. Avoiding intubation. Dani was given Dilaudid for pain. She’s sleeping and her respiratory rate is 4 breaths/minute.
o B. Determining the cause of the attack. If action isn’t taken quickly, she might have which of the following reactions?

o C. Improving exercise tolerance. o A. Asthma attack

o D. Reducing secretions. o B. Respiratory arrest

Incorrect o C. Improve cardiac output

Correct Answer: A. Avoiding intubation o D. Constipation

Inhaled beta-adrenergic agents, I.V. corticosteroids, and supplemental oxygen are used to Correct
reduce bronchospasm, improve oxygenation, and avoid intubation. A favorable response to Correct Answer: B. Respiratory arrest
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 Narcotics can cause respiratory arrest if given in large quantities. Threatening life events are
predicted. to be managed promptly as the respiratory depression it causes in overdose may lead to death.
Hydromorphone is a target of research in intrathecal pumps, which has a promising role in
• Option B: Determining the trigger for the client’s attack is a later goal. Eighty refractory pain. Concurrent use of hydromorphone with other CNS depressants, including
percent to 85% of asthma fatalities are in the subgroup of slow-onset asthma benzodiazepine and barbiturates, can induce severe respiratory and/or CNS depression. For
exacerbation, perhaps reflecting an inadequate disease control over time. In this purpose, the use of alternative analgesic agents is necessary.
contrast to the sudden onset of exacerbation phenotype, which presents
 • Option A: Asthma comprises a range of diseases and has a variety of If the physician suspects that the individual has overdosed on an opiate and
heterogeneous phenotypes. The recognized factors that are associated with has signs of respiratory and CNS depression, no time should be wasted on
asthma are a genetic predisposition, specifically a personal or family history of laboratory studies; instead, naloxone should be administered as soon as
atopy (propensity to allergy, usually seen as eczema, hay fever, and asthma). possible.

• Option C: Hydromorphone is a rapid-acting potent opioid used in acute and • Option C: Reflexes and heart sounds will be part of the more extensive
chronic pain. It is interchangeable with other opioids and has a specific examination done after these initial actions are completed. An ECG is
conversion scale. Hydromorphone is available in multiple forms, including recommended in all patients with suspected opioid overdose. Coingestants
injection and oral forms, immediate-release, and extended-release forms. The like tricyclics have the potential to cause arrhythmias.
risk profile of this drug requires careful prescription and administration, with
thorough knowledge of the potential harms and interactions. • Option D: When a patient presents to the emergency department with any
type of drug overdose, the ABCDE protocol has to be followed. In some cases,
• Option D: Hydromorphone is to be avoided in any gastrointestinal obstruction airway control has been obtained by emergency medical personnel at the
or hypomotility, including ileus. Postoperative ileus should prompt careful scene, but if there is any sign of respiratory distress or failure to protect the
administration of hydromorphone, to prevent prolonged ileus. airways in an un-intubated patient with a morphine overdose, one should not
hesitate to intubate. In most emergency rooms, patients who present with an
23. 23. Question unknown cause of lethargy or loss of consciousness have their blood glucose
Which of the following additional assessment data should immediately be gathered to levels drawn.
determine the status of a client with a respiratory rate of 4 breaths/minute? 24. 24. Question
o A. Arterial blood gas (ABG) and breath sounds. A client is in danger of respiratory arrest following the administration of a narcotic analgesic.
o B. Level of consciousness and a pulse oximetry value. An arterial blood gas value is obtained. The nurse would expect PaCO2 to be which of the
following values?
o C. Breath sounds and reflexes.
o A. 15 mm Hg
o D. Pulse oximetry value and heart sounds.
o B. 30 mm Hg
Correct
o C. 40 mm Hg
Correct Answer: B. Level of consciousness and a pulse oximetry value.
o D. 80 mm Hg
First, the nurse should attempt to rouse the client because this should increase the client’s
respiratory rate. If available, a spot pulse oximetry check should be done and breath sounds Incorrect
should be checked. The physician should be notified immediately of the findings. The care of Correct Answer: D. 80 mm Hg
the patient at the scene depends on the vital signs. If the patient is comatose and in respiratory
distress, airway control must be obtained before doing anything else. A client about to go into respiratory arrest will have inefficient ventilation and will be retaining
carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower
• Option A: He’ll probably order ABG analysis to determine specific carbon than expected. When shunt is predominant above other mechanisms, the hypoxemia is more
dioxide and oxygen levels, which will indicate the effectiveness of ventilation.
severe and refractory to oxygen therapy, meaning that high levels of inspiratory oxygen fraction The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could
(FIO2 >50-60%) are needed to reach PaO2 values between 60 and 70mmHg, as in ARDS. lead to eventual respiratory failure. Respiratory failure is a clinical condition that happens when
the respiratory system fails to maintain its main function, which is gas exchange, in which PaO2
• Option A: In cases of significant alveolar dead space (large areas of lower than 60 mmHg and/or PaCO2 higher than 50 mmHg.
pulmonary parenchyma without perfusion), such as in pulmonary emphysema,
there may be both hypoxemia and hypercapnia due to alveolar hypoventilation • Option A: Although the signs are also related to an asthma attack, consider
and V/Q mismatch, especially if the ventilatory pump could not compensate the new drug first. The overall etiology is complex and still not fully understood,
the baseline disturb. 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
• Option B: The hypoxic ARF is defined by PaO2 levels < 55-60mmHg, in-room wheeze, only 1% of adults have asthma), but it is agreed that it is a
air or with indication for oxygen therapy with no CO2 retention. The pulmonary multifactorial pathology, influenced by both genetics and environmental
causes of hypoxemia or hypercapnia include dead space, impairment of gas exposure.
diffusion, V/Q mismatch, and shunt. It is not always possible to determine
which is the predominant mechanism in a clinical scenario. Different levels of • Option B: Most pulmonary embolisms originate as lower extremity DVTs.
V/Q disorders may coexist in the patient’s pulmonary parenchyma. Hence, risk factors for pulmonary embolism (PE) are the same as risk factors
for DVT. Virchow’s triad of hypercoagulability, venous stasis, and endothelial
• Option C: The hypercapnic ARF is characterized by increased PaCO2 levels injury provides an understanding of these risk factors.
above 45-50mHg with resultant acidemia; pH<7.34. The hypercapnic ARF is
invariably associated with alveolar hypoventilation with resulting in mild • Option D: Rheumatoid arthritis doesn’t manifest these signs. Most common
hypoxemia. In the hypoxemic type, however, the main alteration is the clinical presentation of RA is polyarthritis of small joints of hands: proximal
increased D(A-a)O2 caused by the pulmonary parenchyma disease and interphalangeal (PIP), metacarpophalangeal (MCP) joints, and wrist. Some
ventilation/perfusion (V/Q) mismatch. patients may present with monoarticular joint involvement.

25. 25. Question 26. 26. Question

A client has started a new drug for hypertension. Thirty minutes after he takes the drug, he Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to
develops chest tightness and becomes short of breath and tachypnea. He has a decreased a drug should include which of the following actions first?
level of consciousness. These signs indicate which of the following conditions?
o A. Administering oxygen.
o A. Asthma attack
o B. Inserting an I.V. catheter.
o B. Pulmonary embolism
o C. Obtaining a complete blood count (CBC).
o C. Respiratory failure
o D. Taking vital signs.
o D. Rheumatoid arthritis
Incorrect
Correct
Correct Answer: A. Administering oxygen.
Correct Answer: C. Respiratory Failure
Giving oxygen would be the best first action in this case. Airway management is paramount. Correct
Thoroughly examine the patient for airway patency or any indications of an impending loss of
airway. Perioral edema, stridor, and angioedema are very high risk, and obtaining a definitive Correct Answer: B. Administer bronchodilators.
airway is imperative. Delay may reduce the chances of successful intubation as continued Bronchodilators would help open the client’s airway and improve his oxygenation status.
swelling occurs, increasing the risk for a surgical airway. Bronchodilators are useful adjuncts in patients with bronchospasm. Patients with previous
histories of respiratory disease, most notably asthma are at the highest risk. Treated with
• Option B: If the client doesn’t already have an I.V. catheter, one may be
inhaled beta-agonists are the first-line treatment in wheezing; albuterol alone or as ipratropium
inserted now if anaphylactic shock is developing. Anaphylaxis induces a
bromide/albuterol. If there is refractory wheezing IV magnesium is appropriate with dosage and
distributive shock that typically is responsive to fluid resuscitation and the
treatment similar to severe asthma exacerbations.
above epinephrine. One to 2 L or 10 to 20 mL/kg isotonic crystalloid bolus
should be given for observed hypotension. Albumin or hypertonic solutions are • Option A: Beta-adrenergic blockers aren’t indicated in the management of
not indicated. asthma because they may cause bronchospasm. Corticosteroids are given for
the reduction of length or biphasic response of anaphylaxis. There is minimal
• Option C: Obtaining a CBC wouldn’t help the emergency situation. Laboratory
literature to support this use specifically in anaphylaxis, but it has been proven
testing is of little to no use, as there is no accurate testing for diagnosis or
effective in reactive airway diseases. Therefore, use, dosages, and proposed
confirmation. Serum histamine is of no use due to transient elevation and late
mechanism of action mimic those of airway management protocols.
presentation. Serum tryptase can be considered for confirmation of an
anaphylactic episode as it remains elevated for several hours, however, as a • Option C: Obtaining laboratory values wouldn’t be done on an emergency
diagnostic modality, this has low sensitivity. basis. Laboratory testing is of little to no use, as there is no accurate testing
for diagnosis or confirmation. Serum histamine is of no use due to transient
• Option D: Vital signs then should be checked and the physician immediately
elevation and late presentation. Serum tryptase can be considered for
notified. Anaphylaxis is most often a rapidly evolving presentation, usually
confirmation of an anaphylactic episode as it remains elevated for several
within one hour of exposure. Roughly half of the anaphylactic-related fatalities
hours, however, as a diagnostic modality, this has low sensitivity.
occur within this first hour; therefore, the first hour after the initial symptom
onset is the most crucial for treatment. It is important to note that the more • Option D: Having the client lie flat in bed could worsen his ability to breathe.
rapid the onset and progression of symptoms, the more severe the disease Airway management is paramount. Thoroughly examine the patient for airway
process. patency or any indications of an impending loss of airway. Perioral edema,
27. 27. Question stridor, and angioedema are very high risk, and obtaining a definitive airway is
imperative. Delay may reduce the chances of successful intubation as
Following the initial care of a client with asthma and impending anaphylaxis from continued swelling occurs, increasing the risk for a surgical airway.
hypersensitivity to a drug, the nurse should take which of the following steps next?

o A. Administer beta-adrenergic blockers.

o B. Administer bronchodilators.

o C. Obtain serum electrolyte levels.

o D. Have the client lie flat in the bed.

 28. 28. Question A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the
client is most likely to experience what type of acid-base imbalance?
A client’s ABG results are as follows: pH: 7.16; PaCO2 80 mm Hg; PaO2 46 mm Hg; HCO3-
24 mEq/L; SaO2 81%. This ABG result represents which of the following conditions? o A. Respiratory acidosis

o A. Metabolic acidosis o B. Respiratory alkalosis

o B. Metabolic alkalosis o C. Metabolic acidosis

o C. Respiratory acidosis o D. Metabolic alkalosis

o D. Respiratory alkalosis Incorrect

Incorrect Correct Answer: A. Respiratory acidosis

Correct Answer: C. Respiratory acidosis Respiratory acidosis is most often due to hypoventilation. Chronic respiratory acidosis is most
commonly caused by COPD. In end-stage disease, pathological changes lead to airway
PaCO2 > 40 with a pH < 7.4 indicates a respiratory acidosis. If the pH is in the normal range collapse, air trapping, and disturbance of ventilation-perfusion relationships. Respiratory
(7.35-7.45), use a pH of 7.40 as a cutoff point. In other words, a pH of 7.37 would be acidosis is a state in which there is usually a failure of ventilation and an accumulation of carbon
categorized as acidosis. Arterial blood gas interpretation is best approached systematically. dioxide. The primary disturbance of elevated arterial PCO2 is the decreased ratio of arterial
Interpretation leads to an understanding of the degree or severity of abnormalities, whether the bicarbonate to arterial PCO2, which leads to a lowering of the pH.
abnormalities are acute or chronic, and if the primary disorder is metabolic or respiratory in
origin. • Option B: Respiratory alkalosis may be an acute process or a chronic
process. These are determined based on the level of metabolic compensation
• Option A: Evaluate the respiratory and metabolic components of the ABG for the respiratory disease. Acute respiratory alkalosis is associated with high
results, the PaCO2 and HCO3, respectively. The PaCO2 indicates whether the bicarbonate levels since there has not been sufficient time to lower the HCO3
acidosis or alkalemia is primarily from a respiratory or metabolic levels and chronic respiratory alkalosis is associated with low to normal HCO3
acidosis/alkalosis. levels.
• Option B: The acid-base that is inconsistent with the pH is the HCO3, as it is • Option C: Metabolic acidosis is characterized by an increase in the hydrogen
elevated, indicating a metabolic alkalosis, so there is compensation signifying ion concentration in the systemic circulation resulting in a serum HCO3 less
a non-acute primary disorder because it takes days for metabolic than 24 mEq/L. Metabolic acidosis is not a benign condition and signifies an
compensation to be effective. underlying disorder that needs to be corrected to minimize morbidity and
• Option D: PaCO2 < 40 and pH < 7.4 indicates a respiratory alkalosis (but is mortality.
often from hyperventilation from anxiety or compensation for a metabolic • Option D: Normal human physiological pH is 7.35 to 7.45. A decrease in pH
acidosis). Assess for evidence of compensation for the primary acidosis or below this range is acidosis, an increase over this range is alkalosis. Metabolic
alkalosis by looking for the value (PaCO2 or HCO3) that is not consistent with alkalosis is defined as a disease state where the body’s pH is elevated to
the pH. greater than 7.45 secondary to some metabolic process.
29. 29. Question
 30. 30. Question

A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH
of 7.50 and a PCO2 of 30 mm Hg. The nurse has determined that the client is experiencing
respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

o A. Sodium level of 145 mEq/L

o B. Potassium level of 3.0 mEq/L

o C. Magnesium level of 2.0 mg/L

o D. Phosphorus level of 4.0 mg/dl

Correct

Correct Answer: B. Potassium level of 3.0 mEq/L

Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias,

tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Since the primary cause of all
respiratory alkalosis etiologies is hyperventilation, many patients present complaints of
shortness of breath. The exact history and physical exam findings are highly variable as there
are many pathologies that induce the pH disturbance. Options 1, 3, and 4 identify normal
laboratory values. Option 2 identifies the presence of hypokalemia.

• Option A: In hypoxic patients, it is important to calculate the A-a gradient to

determine the etiology and further diagnosis. If the A-a gradient is wide, be
suspicious of pulmonary embolism and appropriately work up the patient.

• Option C: Serum electrolytes should be measured with particular attention to

sodium, potassium, and calcium levels as aberrations in these may lead to
further complications. Magnesium and phosphate are also essential to
measure.

• Option D: Physical exam findings may be just as varied depending on etiology

to include fever, tachycardia, tachypnea, diaphoresis, hyper or hypotension,
altered mental status, productive or non-productive cough, wheezing, rales,
crackles, cardiac murmur or arrhythmia, jugular venous distension, meningeal
signs, focal neurological loss, Trousseau sign, Chvostek sign, jaundice,
melena, hematochezia, hepatosplenomegaly, or there may be no definitive
signs at all.