SS ATI Practice Assessment Answer Key for Acid Base Mechanical Ventilation Respiratory Failure
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Course
NURS 4581
Institution
NURS 4581
SS ATI Practice Assessment Answer Key for Acid Base Mechanical Ventilation Respiratory Failure
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is
23 mEq/L. The nurse should recognize that these findings indicate of which of the followin...
ss ati practice assessment answer key for acid base mechanical ventilation respiratory failure
a nurse is reviewing the arterial blood gas values for a client the ph is 732
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Detailed Answer Key
Student Success. N4581Resp Practice Questions
1. A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is
23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?
A. Respiratory acidosis
Rationale: A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the
presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH
less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly
elevated (22 to 26 mEq/mL).
B. Respiratory alkalosis
Rationale: Hyperventilation, from acute pain or anxiety, can causes respiratory alkalosis. In the presence of
respiratory alkalosis, the client's blood gas values meet the following criteria: a pH greater than
7.45, a PaCO2 less than 35 mm Hg, and a HCO3 of 22 to 26 mEq/mL.
C. Metabolic acidosis
Rationale: Ketoacidosis can cause metabolic acidosis. In the presence of metabolic acidosis, the client's
blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 that is normal if
uncompensated (35 to 45 mm/Hg), and a HCO3 less than 22 mEq/mL.
D. Metabolic alkalosis
Rationale: Persistent vomiting can cause metabolic alkalosis. In the presence of metabolic acidosis, the
client's blood gas values meet the following criteria: a pH greater than 7.45, a PaCO2 that is
normal if uncompensated (35 to 45 mm/Hg), and a HCO3 that is greater than 26 mEq/mL.
2. A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery
and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired
effects of medications should the nurse identify as most important for the client’s recovery?
A. It decreases the client's level of anxiety.
Rationale: The nurse should assess for and manage the client’s anxiety, as this can result in postoperative
delirium. Following the administration of an opioid medication, the nurse should assess the client
for relief of pain and apprehension. Even though opioid analgesics may decrease the client's
level of anxiety (partially from pain reduction alone), there is another effect that is more
important.
B. It facilitates the client's deep breathing.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify
facilitation of deep breathing as the most important desired effect of opioids aside from pain
relief. Following thoracic type surgeries, the client’s has increased pain with moving, deep
breathing and coughing. Opioid medications help minimize the discomfort experienced with
deep breathing and coughing which prevents the development of postoperative pneumonia. The
nurse should also encourage the client to splint his incision to help minimize pain.
C. It enhances the client's ability to sleep.
Rationale: The nurse should take measures to facilitate sleep in the postoperative client such as providing
Created on:01/15/2021 Page 1
, Detailed Answer Key
Student Success. N4581Resp Practice Questions
quiet time that is undisturbed, dimming lights, and ensuring the client is comfortable and not in
pain. Even though opioid analgesics may increase the client’s ability to relax and sleep, another
effect is more important.
D. It reduces the client's blood pressure.
Rationale: The nurse should closely monitor the cardiac status of the client who is postoperative. The client
who is experiencing pain releases catecholamines which produce vasoconstriction and increase
blood pressure. Even though opioid analgesics may assist in reducing a client’s blood pressure,
another effect is more important.
3. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the
following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base
excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L
A. Respiratory acidosis
Rationale: Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory
function. It can be the result of respiratory depression, seen with anesthesia or opioid
administration; inadequate chest expansion, due to a weakness of the respiratory muscles or
constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction,
or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2),
resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli.
Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45)
and a CO2 level that is higher than the normal reference range (35 – 45 mm Hg).
B. Metabolic acidosis
Rationale: Metabolic acidosis occurs when there is an alteration in the level of hydrogen ions or a reduction
in the amount of bicarbonate available. It can be the result of diabetic ketoacidosis, starvation,
hypoxia, renal or liver failure, dehydration, or diarrhea. Arterial blood gases will reveal a pH that
is lower than the normal reference range (7.35 – 7.45) and a bicarbonate (HCO3) level that is
lower than the normal reference range (21 – 28 mEq/mL).
C. Metabolic alkalosis
Rationale: Metabolic alkalosis occurs when there is an alteration in the level of HCO3 along with an
increase in the pH of the blood. It can be the result when a client ingests too much antacid from
blood transfusions or total parenteral nutrition. It can also occur if the client has prolonged
vomiting or NG suction, takes thiazide diuretics, or has a metabolic disorder such as
hypercortisolism or hyper aldosteronism. Arterial blood gases will reveal a pH that is higher than
the normal reference range (7.35 – 7.45) and an HCO3 level that is higher than the normal
reference range (35 – 45 mm Hg).
D. Respiratory alkalosis
Rationale: Respiratory alkalosis occurs when there is an excessive loss of CO2 through hyperventilation,
mechanical ventilation, fever, overdose of salicylates, or lesions to the central nervous system.
Arterial blood gases will reveal a pH that is higher than the normal reference range (7.35 – 7.45)
and a CO2 level that is lower than the normal reference range (35 – 45 mm Hg).
Created on:01/15/2021 Page 2
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