Chapter 27: Overview of Oxygen and Carbon Dioxide Exchange My Nursing Test Banks

Chapter 27: Overview of Oxygen and Carbon Dioxide Exchange

MULTIPLE CHOICE

1. What respiratory condition or disease results in both increased compliance and increased resistance?

a.

Asthma

b.

Atelectasis

c.

Surfactant deficiency

d.

Bronchopulmonary dysplasia

ANS: A

Compliance is a measure of the relative ease with which the chest wall expands. Resistance is determined primarily by airway size. Asthma results in increased compliance and increased resistance, both of which increase the work of breathing. Atelectasis and surfactant deficiency both decrease compliance but do not affect resistance. Bronchopulmonary dysplasia increases resistance but does not affect compliance.

DIF: Cognitive Level: Understanding REF: p. 1126

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. How much oxygen is contained in ambient air (room air)?

a.

15%

b.

21%

c.

30%

d.

42%

ANS: B

Room air is composed of 21% oxygen, trace amounts of carbon dioxide, and 79% nitrogen.

DIF: Cognitive Level: Understanding REF: p. 1127

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. During a respiratory assessment, the nurse notes a sinking in of soft tissues relative to the cartilaginous and bony thorax. What is the term for this finding?

a.

Grunting

b.

Tachypnea

c.

Retractions

d.

Nasal flaring

ANS: C

Retractions are defined as the sinking of soft tissue relative to the cartilaginous or bony thorax. Retractions can be extreme in severe airway obstruction as the work of breathing increases. Grunting can be a sign of pain in older children with respiratory issues. It serves to increase the end-respiratory pressure, which prolongs the period of oxygen and carbon dioxide exchange across the membrane. Tachypnea is an increase in the respiratory rate above the childs baseline. Nasal flaring, the enlargement of the nostrils, helps reduce nasal resistance and maintains airway patency.

DIF: Cognitive Level: Understanding REF: p. 1133

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4. What test measures the amount of air inhaled and exhaled during any respiratory cycle?

a.

Tidal volume

b.

Vital capacity

c.

Dynamic compliance

d.

Pulmonary resistance

ANS: A

Tidal volume is defined as the amount of air inhaled and exhaled during any respiratory cycle. When it is multiplied by the respiratory rate, the minute volume is obtained. Forced vital capacity is the maximum amount of air that can be expired after maximum inspiration. It is used to monitor individuals with obstructive airway disease. Dynamic compliance is the relationship between the change in volume and pressure difference. Pulmonary resistance measures the changes in pressure with changes in flow on inspiration and expiration.

DIF: Cognitive Level: Understanding REF: p. 1135

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5. What is the best explanation for using pulse oximetry on young children to determine oxygen saturation?

a.

Pulse oximetry is noninvasive.

b.

Pulse oximetry is better than capnography.

c.

Pulse oximetry is more accurate than arterial blood gases.

d.

Pulse oximetry provides intermittent measurements of oxygen.

ANS: A

Pulse oximetry is a noninvasive measure of oxygen saturation of hemoglobin. Capnography measures carbon dioxide inhalation and exhalation. It does not provide information about oxygen saturation. Arterial blood gases provide additional clinical information, including pH, PCO2, bicarbonate, base excess, and PO2. An arterial puncture is required, which can be painful, and continuous monitoring cannot be done without an arterial line. Pulse oximetry can be either intermittent or continuous.

DIF: Cognitive Level: Understanding REF: p. 1138

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

6. It is important to make certain that sensory connectors and oximeters are compatible because incompatible wiring can cause which condition?

a.

Hyperthermia

b.

Electrocution

c.

Pressure necrosis

d.

Burns under sensors

ANS: D

Incompatible wiring can generate considerable heat at the tip of the sensor, resulting in partial- and full-thickness burns. Heat may be generated at the site of the sensor, but it will not result in generalized hyperthermia. Electrocution is not a possibility with oximeters. Pressure necrosis can occur from improperly applied sensors but not from incompatible wiring.

DIF: Cognitive Level: Understanding REF: p. 1139 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

7. What test should the nurse do as a precautionary measure before doing an arterial puncture to obtain an arterial blood sample?

a.

Allen test

b.

Smith test

c.

Venipuncture

d.

Cold compress

ANS: A

The Allen test determines the adequacy of collateral circulation in the extremity distal to the proposed puncture site. If the child does not have satisfactory circulation when the proposed artery is occluded, that extremity is not used. The Smith test, venipuncture, and a cold compress are not done before arterial blood gas sampling.

DIF: Cognitive Level: Applying REF: p. 1136 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

8. Arterial blood gases have just been drawn on a child. What should the nurse do next?

a.

Take the sample to the laboratory immediately.

b.

Pack the sample in ice and take it to the laboratory immediately.

c.

Place the sample in a brown bag until it can be taken to laboratory.

d.

Refrigerate the sample until it can be taken to the laboratory.

ANS: B

Arterial blood gases require careful handling for accurate results. Immediately after obtaining the specimen, the nurse packs it in ice to reduce cellular metabolism and takes it to the laboratory.

DIF: Cognitive Level: Applying REF: p. 1140

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

9. The continuous administration of mist, or aerosolized water, for the treatment of inflammatory conditions of the airways is a common practice that functions in which manner?

a.

Has no proven benefit

b.

Decreases the viscosity of mucus

c.

Decreases bronchoconstriction

d.

Reduces the inflammation of the lower airways

ANS: A

Aerosol therapy or mist therapy with water is not a treatment of choice for inflammatory airway conditions. Some questionable benefit may occur in mild viral croup. The parent and child may experience a reduction in anxiety in a cool, humid environment. Upper airway secretions may be moistened; however, inhaled mist does not affect the viscosity of mucus. Humidity may worsen bronchospasm. Aerosolized medications are able to reduce inflammation of the lower airways, but water does not have this effect.

DIF: Cognitive Level: Understanding REF: p. 1142 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

10. When is bronchial (postural) drainage generally performed?

a.

Before meals and at bedtime

b.

Right before all aerosol therapy

c.

Immediately on arising and at bedtime

d.

Thirty minutes after meals and at bedtime

ANS: A

The therapy should be done at bedtime and before meals or 1 to 1 1/2 hours after meals to avoid stomach upset. Postural drainage is most effective when it is performed after other respiratory therapy interventions, including bronchodilator and nebulizer treatments. Immediately on arising and at bedtime are appropriate times, but postural drainage is usually carried out at least three times each day. Thirty minutes after meals may induce vomiting.

DIF: Cognitive Level: Applying REF: p. 1143 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

11. What nursing consideration is most important in the care of a child on a mechanical ventilator?

a.

Humidification is not necessary.

b.

Respiratory assessment is done by the ventilator.

c.

Positioning the child for comfort and optimum ventilation is necessary.

d.

Support and reassurance are not as important because the child is unconscious.

ANS: C

The ventilator will do the work of breathing, but the nurse must position the child with attention to achieving optimum gas exchange. The reason for mechanical ventilation and the childs comfort are part of the assessment. Mechanical ventilation is usually achieved by intubation or tracheostomy. These routes bypass the humidification that occurs in the upper airway. The ventilator provides some information about the work of breathing, but patient assessment must be done by the nurse. Support and reassurance are always important for both the child and family. Opioids and anxiolytics are often used to decrease the childs anxiety. Careful assessment is indicated.

DIF: Cognitive Level: Applying REF: p. 1149 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

12. What intervention is necessary when weaning a child from the ventilator?

a.

Light sedation before scheduled extubation

b.

No suctioning before scheduled extubation

c.

Cool mist begun immediately after extubation

d.

Vigorous chest physiotherapy and suctioning performed immediately after extubation

ANS: C

A cool mist or noninvasive oxygen therapy is initiated immediately after extubation. Steroids may be administered to minimize any laryngeal edema. Analgesics may be given, but sedation is not usually indicated. The child is suctioned just before extubation to ensure that the airway is clear. Chest physiotherapy and suctioning are performed before extubation.

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13. The nurse must suction a 6-month-old infant with a tracheostomy. What intervention should be included?

a.

Encourage the child to cough to raise the secretions before suctioning.

b.

Perform each pass of the suction catheter for no longer than 5 seconds.

c.

Allow the child to rest after every five times the suction catheter is passed.

d.

Select a catheter with a diameter three quarters of the diameter of the tracheostomy tube.

ANS: B

Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be occluded for too long. An infant would be unable to cooperate with instructions to cough up secretions. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until the trachea is clear. The catheter should have a diameter one half the size of the tracheostomy tube. If it is too large, it might block the childs airway.

DIF: Cognitive Level: Applying REF: p. 1152

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14. A 3-year-old child with a tracheostomy will soon be discharged. What recommendation should the nurse share with the family?

a.

Tub baths cannot be given.

b.

The child cannot be allowed to play outdoors.

c.

Avoid exposure to noxious fumes such as paint or varnish.

d.

Cover the tracheostomy with a plastic bib when exposed to cold air.

ANS: C

The child with a tracheostomy should not be exposed to noxious fumes such as paint, varnish, or hair spray or to substances such as talc. The parent and child must be cautioned about safety measures around bodies of water. Baths can be taken, but parents must observe the necessary safety precautions. The child may play outdoors with a scarf or other protection that allows air through.

DIF: Cognitive Level: Applying REF: p. 1155

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

15. The nurse is planning home care for a 2-year-old child with a tracheostomy. What recommendation should be included?

a.

Sterile technique is essential in home care of the tracheostomy.

b.

Parents are able to change the tracheostomy tube when needed.

c.

Play activities must be sedentary such as listening to music and working on puzzles.

d.

The child must wear a plastic bib when eating or drinking to prevent aspiration into the stoma.

ANS: B

A plugged, clogged, or obstructed tracheostomy tube is a life-threatening circumstance. Parents are taught the signs and symptoms, how to suction, and how to change the tube. Clean technique and thorough hand washing are sufficient for suctioning, cleaning the tracheostomy site, and changing the tracheostomy tube. The child who is physically able can engage in activities appropriate to age. Young children who may spill food near the stoma should wear a fabric bib without a plastic lining or other device to prevent dribbled food and crumbs from being aspirated.

DIF: Cognitive Level: Applying REF: p. 1155

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

16. Respiratory failure can result from many causes. What condition is a specific primary cause of inefficient gas transfer?

a.

Anemia

b.

Pneumothorax

c.

Cystic fibrosis

d.

Laryngospasm

ANS: A

Respiratory failure is defined as the inability of the respiratory system to maintain adequate oxygenation of the blood. In primary inefficient gas transfer, there is insufficient alveolar ventilation. Anemia, which is characterized by low hemoglobin levels, results in an inability to adequately oxygenate the blood. Pneumothorax and cystic fibrosis are examples of restrictive lung disease. Laryngospasm is an example of obstructive lung disease.

DIF: Cognitive Level: Understanding REF: p. 1127

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

17. The nurse is caring for a child with a tracheostomy. What clinical manifestation should the nurse recognize as an early sign of impending respiratory distress or failure?

a.

Cyanosis

b.

Restlessness

c.

Audible stridor

d.

Crowing respirations

ANS: B

Signs of hypoxemia are initially subtle. Cardinal signs of impending respiratory failure include restlessness, tachypnea, tachycardia, and diaphoresis. Cyanosis is a sign of severe hypoxia. Stridor and crowing respirations are indicative of inflammation. Sternal retractions are an early but less obvious sign.

DIF: Cognitive Level: Understanding REF: p. 1157

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

18. Cardiopulmonary resuscitation is begun on a toddler. What pulse is usually palpated because it is the most central and accessible?

a.

Radial

b.

Carotid

c.

Femoral

d.

Brachial

ANS: B

In a toddler, the carotid pulse is palpated. The radial pulse is not considered a central pulse. The femoral pulse is not the most central and accessible. Brachial pulse is felt in infants younger than 1 year of age.

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TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

19. What medication is considered to be the most useful in treating cardiac arrest?

a.

Bretylium tosylate (Bretylium)

b.

Xylocaine (lidocaine)

c.

Adrenaline (epinephrine)

d.

Naloxone (Narcan)

ANS: C

Epinephrine is considered one of the most useful drugs in treating cardiac arrest. As an adrenergic agent, it acts on both a and b-receptors in the heart. Epinephrine is rapidly cleared from the bloodstream. Bretylium is no longer used in pediatric cardiac arrest management. Lidocaine is used for ventricular arrhythmias only. Naloxone is useful only to reverse effects of opioids.

DIF: Cognitive Level: Applying REF: p. 1150

TOP: Nursing Process: Implementation

MSC: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

20. Effective cardiopulmonary resuscitation (CPR) on a 5-year-old child should include what technique?

a.

Provide one breath to every five chest compressions.

b.

Provide two breaths to every 30 chest compressions.

c.

Reassess the child every 10 minutes while CPR continues.

d.

Evaluate the child after 50 cycles of compression and ventilation.

ANS: B

Two breaths to 15 compressions is the standard for infants and children when two rescuers are present. One breath to every five chest compressions is not the appropriate ratio for CPR in this age group. Reassessment of the child should take place after 20 cycles or 1 minute.

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TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

21. A series of subdiaphragmatic abdominal thrusts (the Heimlich maneuver) is recommended for airway obstruction in children older than which age?

a.

1 year

b.

4 years

c.

8 years

d.

12 years

ANS: A

A series of subdiaphragmatic abdominal thrusts (the Heimlich maneuver) is recommended for airway obstruction in children older than 1 year. For children younger than 1 year, back blows and chest thrusts are administered.

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TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

22. The mother of a toddler yells to the nurse, Help! He is choking to death on his food! The nurse determines that lifesaving measures are necessary based on which finding?

a.

Gagging

b.

Coughing

c.

Pulse over 100 beats/min

d.

Inability to speak

ANS: D

The inability to speak is indicative of a foreign body airway obstruction of the larynx. Abdominal thrusts are needed for treatment of the choking child. Gagging, not obstruction, indicates irritation at the back of the throat. Coughing does not indicate a complete airway obstruction. Tachycardia may be present for many reasons.

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TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

23. The nurse is caring for a 4-year-old child who is receiving 2 L of oxygen per nasal cannula. What disadvantage should the nurse consider when planning care for the child?

a.

The child may need to have high humidity administered with the oxygen.

b.

The child may not be able to eat and drink comfortably.

c.

A nasal cannula may cause an accumulation of moisture on the face.

d.

A nasal cannula may cause abdominal distention.

ANS: D

All oxygen delivery systems have advantages and disadvantages. One disadvantage of a nasal cannula is possible abdominal distention and discomfort, which could lead to vomiting. The advantages include that the child is able to eat and drink more comfortably, there is no need for a high humidity environment, and there is no accumulation of moisture causing skin irritation.

DIF: Cognitive Level: Applying REF: p. 1141 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

24. A 5-month-old infant is in respiratory distress. What should the nurse expect to find?

a.

Nasal flaring

b.

Bradycardia

c.

Abdominal breathing

d.

Capillary refill of 2 seconds

ANS: A

Nasal flaring is a sign of respiratory distress and a significant finding in an infant. The enlargement of the nostrils helps reduce nasal resistance and maintains airway patency. Nasal flaring may be intermittent or continuous and should be described as minimum or marked. The infant would have tachycardia, not bradycardia, in respiratory distress. Abdominal breathing and a capillary refill are normal findings in an infant.

DIF: Cognitive Level: Applying REF: p. 1157 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

25. A child is in uncompensated respiratory acidosis. What should the nurse expect the arterial blood gas to be?

a.

O2, 95; CO2, 45; pH, 7.40

b.

O2, 88; CO2, 55; pH, 7.30

c.

O2, 88; CO2, 35; pH, 7.28

d.

O2, 92; CO2, 54; pH, 7.35

ANS: B

Respiratory acidosis results from diminished or inadequate pulmonary ventilation that causes an elevation in plasma Pco2 and thus an increased concentration of dissolved carbonic acid, which leads to elevated carbonic acid and hydrogen ion concentration. This tends to lower the pH. CO2 of 55 is elevated (normal CO2 is 3545), and a pH of 7.30 is low (normal pH is 7.357.45).

DIF: Cognitive Level: Analyzing REF: p. 1130 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

26. A child is in uncompensated respiratory alkalosis. What should the nurse expect the arterial blood gas to be?

a.

CO2, 30; pH, 7.50

b.

CO2, 55; pH, 7.30

c.

CO2, 35; pH, 7.28

d.

CO2, 54; pH, 7.35

ANS: A

Laboratory findings in respiratory alkalosis include reduced PCO2 (<35?9?mm?9?Hg) and elevated plasma pH (>7.45).

DIF: Cognitive Level: Analyzing REF: p. 1131 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

27. A child is in uncompensated metabolic alkalosis. What should the nurse expect the arterial blood gas to be?

a.

HCO3, 24; pH, 7.35

b.

HCO3, 28; pH, 7.50

c.

HCO3, 20; pH, 7.30

d.

HCO3, 26; pH, 7.40

ANS: B

Metabolic alkalosis results in an elevated plasma pH (normal pH is 7.357.45) that occurs when there is an excess of bicarbonate (normal HCO3 is 2226).

DIF: Cognitive Level: Analyzing REF: p. 1132 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

28. A child is in uncompensated metabolic acidosis. What should the nurse expect the arterial blood gas to be?

a.

HCO3, 24; pH, 7.35

b.

HCO3, 28; pH, 7.50

c.

HCO3, 20; pH, 7.30

d.

HCO3, 26; pH, 7.40

ANS: C

Laboratory findings of uncompensated metabolic acidosis include lowered plasma pH (<7.35) and diminished plasma bicarbonate concentration (normal HCO3 is 2226).

DIF: Cognitive Level: Analyzing REF: p. 1132 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

29. A nurse is calculating the correlation of Pao2 with Sao2 according to the oxyhemoglobin dissociation curve. What parameter should indicate that the Pao2 is less than 50 to 60 mm Hg?

a.

Coarse lung sounds

b.

Temperature of 100 F

c.

Respiratory rate of 58

d.

Pulse oximetry reading of 90% or less

ANS: D

The Pao2 can be correlated with the Sao2 by means of the oxyhemoglobin dissociation curve, although changes in Pao2 do not cause identical (linear) changes in Sao2. The curve represents the relationship between Pao2(measured in the blood) and Sao2 (measured by the pulse oximeter). When the Pao2 is 60?9?mm?9?Hg, the Sao2 is 90%. The oxyhemoglobin dissociation curve does not correlate with lung sounds, temperature, or respiratory rate.

DIF: Cognitive Level: Applying REF: p. 1139

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

30. The nurse is reviewing factors that affect lung development. What factor delays surfactant production and maturation of alveolar cells?

a.

Thyroxine

b.

Prolactin

c.

Glucocorticosteroids

d.

Excess of endogenous insulin

ANS: D

An excess of endogenous insulin can delay surfactant production and delays maturation of alveolar cells. Glucocorticosteroids, thyroxine, and prolactin enhance lung development.

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TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

31. The nurse is caring for a child in respiratory distress. What is an early but less obvious sign of respiratory failure?

a.

Stupor

b.

Headache

c.

Bradycardia

d.

Somnolence

ANS: B

An early but less obvious sign of respiratory failure is a headache. Stupor, bradycardia, and somnolence are signs of more severe hypoxia.

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TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

32. The nurse is caring for a child on oxygen being delivered by a nasal cannula. What is the advantage of delivering oxygen in this manner?

a.

It can deliver mist if desired.

b.

It is less likely to cause abdominal distention.

c.

The child is able to eat and talk while getting oxygen.

d.

This method can deliver a higher concentration of oxygen.

ANS: C

An advantage of delivering oxygen by nasal cannula is that the child is able to eat and talk while getting oxygen. This method cannot deliver mist or higher concentrations of oxygen. A disadvantage of this method is that it may cause abdominal distention.

DIF: Cognitive Level: Analyzing REF: p. 1141 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

33. The nurse is evaluating arterial blood gas results. What condition can cause an increase in PCO2?

a.

Hypoxia

b.

Hyperventilation

c.

Pulmonary embolism

d.

Obstructive lung disease

ANS: D

Obstructive lung disease causes an increase in PCO2. Hypoxia, hyperventilation, and pulmonary embolism cause a decrease in PCO2.

DIF: Cognitive Level: Analyzing REF: p. 1138 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

34. The nurse is evaluating arterial blood gas results. What condition can cause an increase in HCO3?

a.

Renal failure

b.

Lactic acidosis

c.

Diabetic ketoacidosis

d.

Fluid loss from upper gastrointestinal tract

ANS: D

Fluid loss from an upper gastrointestinal tract causes an increase in HCO3. Renal failure, lactic acidosis, and diabetic ketoacidosis cause a decrease in HCO3.

DIF: Cognitive Level: Analyzing REF: p. 1138 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

35. The nurse is analyzing an arterial blood gas of pH, 7.30; PCO2, 50; and HCO3, 29. What result should the nurse document for this blood gas?

a.

Fully compensated respiratory acidosis

b.

Partially compensated respiratory acidosis

c.

Fully compensated metabolic acidosis

d.

Partially compensated metabolic acidosis

ANS: B

When the fundamental acidbase ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acidbase pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In respiratory acidosis, the pH is low (?6?7.35), and the PCO2 is high (?7?45). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the HCO3 is high (?7?26), indicating an attempt at compensation.

DIF: Cognitive Level: Analyzing REF: p. 1129

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Physiological Integrity

36. The nurse is analyzing an arterial blood gas of pH, 7.50; PCO2, 50; and HCO3, 29. What result should the nurse document for this blood gas?

a.

Fully compensated metabolic alkalosis

b.

Partially compensated metabolic alkalosis

c.

Fully compensated respiratory alkalosis

d.

Partially compensated respiratory alkalosis

ANS: B

When the fundamental acidbase ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acidbase pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In metabolic alkalosis, the pH is high (?7?7.45), and the HCO3 is high (?7?26). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the PCO2 is high (?7?45), indicating an attempt at compensation.

DIF: Cognitive Level: Analyzing REF: p. 1129

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Physiological Integrity

37. The nurse is analyzing an arterial blood gas of pH, 7.29; PCO2, 30; and HCO3, 20. What result should the nurse document for this blood gas?

a.

Fully compensated respiratory acidosis

b.

Partially compensated respiratory acidosis

c.

Fully compensated metabolic acidosis

d.

Partially compensated metabolic acidosis

ANS: D

When the fundamental acidbase ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acidbase pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In metabolic acidosis, the pH is low (?6?7.35), and the HCO3 is low (?6?22). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the PCO2 is low (?6?35), indicating an attempt at compensation.

DIF: Cognitive Level: Analyzing REF: p. 1129

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Physiological Integrity

38. The nurse is analyzing an arterial blood gas of pH, 7.50; PCO2, 30; and HCO3, 20. What result should the nurse document for this blood gas?

a.

Fully compensated metabolic alkalosis

b.

Partially compensated metabolic alkalosis

c.

Fully compensated respiratory alkalosis

d.

Partially compensated respiratory alkalosis

ANS: D

When the fundamental acidbase ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acidbase pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In respiratory alkalosis, the pH is high (?7?7.45), and the PCO2 is low (?6?35). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the HCO3 is low (?6?22), indicating an attempt at compensation.

DIF: Cognitive Level: Analyzing REF: p. 1131

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1. What conditions can produce hyperventilation? (Select all that apply.)

a.

Hysteria

b.

Narcotics

c.

Atelectasis

d.

Salicylate intoxication

e.

Mechanical ventilation

ANS: A, D, E

Hysteria, salicylate intoxication, and mechanical ventilation can produce hyperventilation. Narcotics and atelectasis produce inadequate gas exchange, not hyperventilation.

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TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. What condition or disease decreases lung compliance? (Select all that apply.)

a.

Asthma

b.

Atelectasis

c.

Pneumothorax

d.

Pulmonary edema

e.

Lobar emphysema

ANS: B, C, D

Atelectasis, pneumothorax, and pulmonary edema decrease lung compliance. Asthma and lobar emphysema increase lung compliance.

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TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. The nurse is caring for an intubated child on mechanical ventilation. What interventions should the nurse implement to prevent ventilator-assisted pneumonia (VAP)? (Select all that apply.)

a.

Routine oral hygiene

b.

Appropriate hand hygiene

c.

Limit oropharyngeal suctioning of secretions

d.

Elevating the head of the bed 30 to 45 degrees

e.

Wearing gloves to handle respiratory secretions

ANS: A, B, D, E

Critically ill children on mechanical ventilation are at risk for acquisition of VAP. To prevent VAP, recommendations for nurses working with mechanically ventilated patients include appropriate hand hygiene measures; wearing gloves to handle respiratory secretions or contaminated objects; elevating the head of the bed 30 to 45 degrees; and routine oral hygiene, which includes oropharyngeal suctioning of secretions.

DIF: Cognitive Level: Applying REF: p. 1141

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

4. The nurse recognizes that oxygen mist tents are rarely used for a child with respiratory distress. What are reasons for not using an oxygen mist tent? (Select all that apply.)

a.

Poor access to the child

b.

Cool and wet tent environment

c.

Oxygen levels fall when tent is entered

d.

Child may not tolerate it around the crib/bed

e.

Lower oxygen concentrations cannot be achieved

ANS: A, B, C, D

The disadvantages of using a mist tent include poor access to the child, a cool and wet tent environment, oxygen levels fall when the tent is entered, and the child may not tolerate it around the crib or bed. Lower oxygen concentrations can be achieved in the tent and is an advantage.

DIF: Cognitive Level: Analyzing REF: p. 1156 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

COMPLETION

1. The nurse is participating in a code blue on a 12-year-old child in a full respiratory arrest. The child weighs 110 lb. The health care provider has ordered an initial dose of epinephrine hydrochloride (1:10,000) given intravenously. Calculate the correct initial dose of epinephrine in mg. Record your answer using one decimal place.

_____________

ANS:

0.5

The correct calculation is:

110 lb/2.2 kg = 50 kg

Initial dose of 1:10,000 epinephrine is 0.01 mg/kg

0.01 mg 50 = 0.5 mg

DIF: Cognitive Level: Applying REF: p. 1157 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

2. The nurse is calculating the amount of expected urinary output for a 24-hour period on an intubated young child who weighs 22 lb. The nurse recognizes the formula to be used is 2 ml/kg/hr. What is the expected 24-hour urinary output for this child in milliliters? Record your answer below in a whole number.

_____________

ANS:

4840

Perform the calculation.

22/2.2 = 10 kg

10 2 24 = 480 ml

DIF: Cognitive Level: Understanding REF: p. 1157

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. The nurse is calculating the amount of expected urinary output for a 24-hour period on an intubated young child who weighs 33 lb. The nurse recognizes the formula to be used is 2 ml/kg/hr. What is the expected 24-hour urinary output for this child in milliliters? Record your answer below in a whole number.

_____________

ANS:

720

Perform the calculation.

33/2.2 = 15 kg

15 2 24 = 720 ml

DIF: Cognitive Level: Understanding REF: p. 1157

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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