1. 1.

Question
An elderly client with pneumonia may appear with which of the following symptoms first?
o A. Altered mental status and dehydration
o B. Fever and chills
o C. Hemoptysis and dyspnea
o D. Pleuritic chest pain and cough
Correct
Correct Answer: A. Altered mental status and dehydration
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
dehydration due to a blunted immune response. Pneumonia is a common cause of mortality
and morbidity. It can have a myriad of clinical presentations and can pose a diagnostic
dilemma especially in the setting of severely ill patients with several comorbidities and
underlying lung pathologies.
 Option B: Historically, the chief complaints in case of pneumonia include
systemic signs like fever with chills, malaise, loss of appetite, and myalgias.
These findings are more common in viral pneumonia as compared to bacterial
pneumonia.
 Option C: Pulmonary findings include cough with or without sputum
production. Bacterial pneumonia is associated with purulent or rarely blood-
tinged sputum. Viral pneumonia is associated with watery or occasionally
mucopurulent sputum production.
 Option D: There may be an associated pleuritic chest pain with the
concomitant involvement of the pleura. Dyspnea and a diffuse heaviness of the
chest are also seen occasionally. Complications of untreated or under-treated
pneumonia include respiratory failure, sepsis, metastatic infections, empyema,
lung abscess, and multi-organ dysfunction.
2. 2. Question
Which of the following pathophysiological mechanisms that occur in the lung parenchyma
allows pneumonia to develop?
o A. Atelectasis
o B. Bronchiectasis
o C. Effusion
o D. Inflammation
Correct
Correct Answer: D. Inflammation
The most common feature of all types of pneumonia is an inflammatory pulmonary response
to the offending organism or agent. The resident macrophages serve to protect the lung from
foreign pathogens. Ironically, the inflammatory reaction triggered by these very macrophages
is what is responsible for the histopathological and clinical findings seen in pneumonia.
 Option A: Atelectasis indicates a collapse of a portion of the airway that
doesn’t occur with pneumonia. It is caused by the partial or complete,
reversible collapse of the small airways resulting in an impaired exchange of
CO2 and O2 – i.e., intrapulmonary shunt. The incidence of atelectasis in
patients undergoing general anesthesia is 90%.
 Option B: Bronchiectasis is a chronic lung disease characterized by persistent
and lifelong widening of the bronchial airways and weakening of the function
mucociliary transport mechanism owing to repeated infection contributing to
bacterial invasion and mucus pooling throughout the bronchial tree.
 Option C: An effusion is an accumulation of excess pleural fluid in the
pleural space, which may be a secondary response to pneumonia.
Accumulation of excess fluid can occur if there is excessive production or
decreased absorption or both overwhelming the normal homeostatic
mechanism. If pleural effusion 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 (usually exudates) or impaired lymphatic drainage.
3. 3. Question
A 7-year-old client is brought to the E.R. He’s tachypneic and afebrile and has a respiratory
rate of 36 breaths/minute and a nonproductive cough. He recently had a cold. From his
history, the client may have which of the following?
o A. Acute asthma
o B. Bronchial pneumonia
o C. Chronic obstructive pulmonary disease (COPD)
o D. Emphysema
Correct
Correct Answer: A. Acute asthma
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. There is often diurnal variation, with symptoms being worse at night. Many
asthmatics have 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 or emphysema.
  Option B: Recurrent episodes of acute shortness of breath, typically occurring
at night or in the early morning hours, are the cardinal manifestation of
bronchial asthma. Further symptoms include cough, wheezing, and a feeling
of tightness in the chest. Auscultation of the chest reveals rales, rhonchi, and
wheezes.
 Option C: It is associated with structural lung changes due to chronic
inflammation from prolonged exposure to noxious particles or gases most
commonly cigarette smoke. Chronic inflammation causes airway narrowing
and decreased lung recoil. Patients usually present with complaints of chronic
and progressive dyspnea, cough, and sputum production. Patients may also
have wheezing and chest tightness.
 Option D: Most patients present with very nonspecific symptoms of chronic
shortness of breath and cough with or without sputum production. As the
disease process advances, the shortness of breath and cough progressively gets
worse. Initially, there is exertional dyspnea with significant physical activity,
especially arm work at or above shoulder level with progression to dyspnea
with simple daily activities and even at rest. Some patients may present with
wheezing because of the airflow obstruction.
4. 4. Question
Which of the following assessment findings would help confirm a diagnosis of asthma in a
client suspected of having the disorder?
o A. Circumoral cyanosis
o B. Increased forced expiratory volume
o C. Inspiratory and expiratory wheezing
o D. Normal breath sounds
Correct
Correct Answer: C. Inspiratory and expiratory wheezing
Inspiratory and expiratory wheezes are typical findings in asthma. Patients will show some
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,
as air cannot enter or leave the lungs, and there may be signs of systemic hypoxia.
 Option A: Circumoral cyanosis may be present in extreme cases of respiratory
distress. In many cases, circumoral cyanosis is considered a type of
acrocyanosis. Acrocyanosis happens when small blood vessels shrink in
response to cold. In older children, circumoral cyanosis often appears when
they go outside in cold weather or get out of a warm bath. This type of
cyanosis should go away once they warm up. If it doesn’t, seek emergency
medical treatment. Circumoral cyanosis that doesn’t go away with heat could
be a sign of a serious lung or heart problem, such as cyanotic congenital heart
disease.
  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
response to therapy. A limitation of this test is that it is effort-dependent.
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,
which is reversible with treatment.
 Option D: Breath sounds will be “tight” sounding or markedly decreased;
they won’t be normal. Asthma is a condition mediated by inflammation. The
resulting physiologic response in the airways is bronchoconstriction and
airway edema. This response is triggered by an irritant, allergen, or infection.
As air moves through these narrowed airways, the primary lung sound is high-
pitched wheeze.
5. 5. Question
Which of the following types of asthma involves an acute asthma attack brought on by an
upper respiratory infection?
o A. Emotional
o B. Extrinsic
o C. Intrinsic
o D. Mediated
Correct
Correct Answer: C. Intrinsic
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
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
extrinsic asthma, those with intrinsic asthma usually have a negative allergy skin test, so they
often won’t benefit from allergy shots or allergy medications.
 Option A: Asthma caused by emotional reasons is considered to be in the
extrinsic category. Strong emotions and stress are well-known triggers of
asthma. There is evidence of a link between asthma, anxiety, and depression,
though the outcomes are sometimes not consistent. Anxiety and depression
may be associated with poor asthma control.
 Option B: Extrinsic asthma is caused by dust, molds, and pets; easily
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
higher levels of IgE (Immunoglobulin E) present in the blood test.
 Option D: Mediated asthma doesn’t exist. When airflow is obstructed as a
result of exercise, it’s known as exercise-induced bronchoconstriction (EIB),
 which is a subcategory of asthma. EIB was previously known as exercise-
induced asthma; however, exercise-induced asthma incorrectly implies that
exercise is the underlying cause of asthma when it is actually its trigger, not
the cause.
6. 6. Question
A client with acute asthma showing inspiratory and expiratory wheezes and a decreased
expiratory volume should be treated with which of the following classes of medication right
away?
o A. Beta-adrenergic blockers
o B. Bronchodilators
o C. Inhaled steroids
o D. Oral steroids
Correct
Correct Answer: B. Bronchodilators
Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the
cause of reduced airflow. Bronchodilators are indicated for individuals that have lower than
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
bronchodilators, including asthma and chronic obstructive pulmonary disease.
 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
velocity. B1 receptors also induce renin release, and this leads to an increase in
blood pressure. In contrast, binding to B2 receptors causes relaxation of the
smooth muscles along with increased metabolic effects such as
glycogenolysis.
 Option C: Inhaled steroids may be given to reduce the inflammation but
aren’t used for emergency relief. Inhaled corticosteroids have potent
glucocorticoid activity and work directly at the cellular level by reversing
capillary permeability and lysosomal stabilization to reduce inflammation. The
onset of action is gradual and may take anywhere from several days to several
weeks for maximal benefit with consistent use.
 Option D: Corticosteroids produce their effect through multiple pathways. In
general, they produce anti-inflammatory and immunosuppressive effects,
protein and carbohydrate metabolic effects, water and electrolyte effects,
central nervous system effects, and blood cell effects. Oral administration is
more common for chronic treatment. Patients should receive non-systemic
therapy whenever possible, to minimize systemic exposure.
7. 7. Question
A 19-year-old comes into the emergency department with acute asthma. His respiratory rate
is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the
following actions should be taken first?
o A. Take a full medication history.
o B. Give a bronchodilator by nebulizer.
o C. Apply a cardiac monitor to the client.
o D. Provide emotional support to the client.
Correct
Correct Answer: B. Give a bronchodilator by nebulizer.
The client is having an acute asthma attack and needs to increase oxygen delivery to the lung
and body. Nebulized bronchodilators open airways and increase the amount of oxygen
delivered. Medical management includes bronchodilators like beta-2 agonists and muscarinic
antagonists (salbutamol and ipratropium bromide respectively) and anti-inflammatories such
as inhaled steroids (usually beclomethasone but steroids via any route will be helpful).
 Option A: First, resolve the acute phase of the attack and how to prevent
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
some respiratory distress, often sitting forward to splint open their airways.
 Option C: It may not be necessary to place the client on a cardiac monitor
because he’s only 19-years-old unless he has a past medical history of cardiac
problems. On auscultation, a bilateral, expiratory wheeze will be heard. In life-
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: Measures to take include calming the patient to get them to relax,
moving outside or away from the likely source of allergen, and cooling the
person. Removing clothing and washing the face and mouth to remove
allergens is sometimes done, but it is not evidence-based.
8. 8. Question
A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day
has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based
on this information, he most likely has which of the following conditions?
o A. Adult respiratory distress syndrome (ARDS)
o B. Asthma
o C. Chronic obstructive bronchitis
o D. Emphysema
Correct
Correct Answer: C. Chronic obstructive bronchitis
Because of his extensive smoking history and symptoms, the client most likely has chronic
obstructive bronchitis. Chronic bronchitis is a type of chronic obstructive pulmonary disease
(COPD) that is defined as a productive cough of more than 3 months occurring within a span
of 2 years. Patients typically present with chronic productive cough, malaise, and symptoms
of excessive coughing such as chest or abdominal pain.
 Option A: Clients with ARDS have acute symptoms of and typically need
large amounts of oxygen. Acute respiratory distress syndrome (ARDS) is a
life-threatening condition characterized by poor oxygenation and non-
compliant or “stiff” lungs. The disorder is associated with capillary endothelial
injury and diffuse alveolar damage. Once ARDS develops, patients usually
have varying degrees of pulmonary artery vasoconstriction and may
subsequently develop pulmonary hypertension.
 Option B: Clients with asthma tend not to have a chronic cough or peripheral
edema. 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 in childhood and is associated with other features of atopy, such as
eczema and hayfever. Asthma is a condition of acute, fully reversible airway
inflammation, often following exposure to an environmental trigger.
 Option D: Most patients present with very nonspecific symptoms of chronic
shortness of breath and cough with or without sputum production. As the
disease process advances, the shortness of breath and cough progressively gets
worse. Initially, there is exertional dyspnea with significant physical activity,
especially arm work at or above shoulder level with progression to dyspnea
with simple daily activities and even at rest. Some patients may present with
wheezing because of the airflow obstruction.
9. 9. Question
The term “blue bloater” refers to which of the following conditions?
o A. Adult respiratory distress syndrome (ARDS)
o B. Asthma
o C. Chronic obstructive bronchitis
o D. Emphysema
Correct
Correct Answer: C. Chronic obstructive bronchitis
Clients with chronic obstructive bronchitis appear bloated; they have large barrel chests and
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.
Blue bloaters often take deeper breaths but can’t take in the right amount of oxygen.
 Option A: Clients with ARDS are acutely short of breath and frequently need
intubation for mechanical ventilation and large amounts of oxygen. Clients
 with ARDS have acute symptoms and typically need large amounts of oxygen.
Acute respiratory distress syndrome (ARDS) is a life-threatening condition
characterized by poor oxygenation and non-compliant or “stiff” lungs. The
disorder is associated with capillary endothelial injury and diffuse alveolar
damage. Once ARDS develops, patients usually have varying degrees of
pulmonary artery vasoconstriction and may subsequently develop pulmonary
hypertension.
 Option B: Clients with asthma don’t exhibit characteristics of chronic disease.
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
in childhood and is associated with other features of atopy, such as eczema and
hayfever. Asthma is a condition of acute, fully reversible airway inflammation,
often following exposure to an environmental trigger.
 Option D: Clients with emphysema appear pink and cachectic (a state of ill
health, malnutrition, and wasting). 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 faces redden while
gasping for air.
10. 10. Question
The term “pink puffer” refers to the client with which of the following conditions?
o A. ARDS
o B. Asthma
o C. Chronic obstructive bronchitis
o D. Emphysema
Correct
Correct Answer: D. Emphysema
Because of the large amount of energy it takes to breathe, clients with emphysema are usually
cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer”.
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
faces redden while gasping for air.
 Option A: Clients with ARDS are usually acutely short of breath. Clients with
ARDS have acute symptoms of and typically need large amounts of oxygen.
Acute respiratory distress syndrome (ARDS) is a life-threatening condition
characterized by poor oxygenation and non-compliant or “stiff” lungs. The
disorder is associated with capillary endothelial injury and diffuse alveolar
damage. Once ARDS develops, patients usually have varying degrees of
pulmonary artery vasoconstriction and may subsequently develop pulmonary
hypertension.
  Option B: Clients with asthma don’t have any particular characteristics.
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
in childhood and is associated with other features of atopy, such as eczema and
hayfever. Asthma is a condition of acute, fully reversible airway inflammation,
often following exposure to an environmental trigger.
 Option C: Clients with chronic obstructive bronchitis are bloated and cyanotic
in appearance. Clients with chronic obstructive bronchitis appear bloated; they
have large barrel chests and 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. Blue
bloaters often take deeper breaths but can’t take in the right amount of oxygen.
11. 11. Question
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
forward with his arms braced on his knees to support his chest and shoulders for breathing.
This client has symptoms of which of the following respiratory disorders?
o A. ARDS
o B. Asthma
o C. Chronic obstructive bronchitis
o D. Emphysema
Correct
Correct Answer: D. Emphysema
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
referred to as “pink puffers,” meaning cachectic and non-cyanotic. Expiration through pursed
lips increases airway pressure and prevents airway collapse during respiration, and the use of
accessory muscles of respiration indicates advanced disease.
 Option A: Clients with ARDS are acutely short of breath and require
emergency care. The physical examination will include findings associated
with the respiratory system, such as tachypnea and increased effort to breathe.
Systemic signs may also be evident depending on the severity of illness, such
as central or peripheral cyanosis resulting from hypoxemia, tachycardia, and
altered mental status. Despite 100% oxygen, patients have low oxygen
saturation.
 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
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 episodes occurring for 2 years in a row. A productive cough
with sputum is present in about 50% of patients.
12. 12. Question
It’s highly recommended that clients with asthma, chronic bronchitis, and emphysema have
Pneumovax and flu vaccinations for which of the following reasons?
o A. All clients are recommended to have these vaccines.
o B. These vaccines produce bronchodilation and improve oxygenation.
o C. These vaccines help reduce the tachypnea these clients experience.
o D. Respiratory infections can cause severe hypoxia and possibly death in
these clients.
Correct
Correct Answer: D. Respiratory infections can cause severe hypoxia and possibly death
in these clients.
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
mechanical ventilation, and it may be difficult to wean these clients from the ventilator.
Another 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 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 excluding hypertension, chronic lung disease including asthma, diabetes mellitus,
cerebrospinal fluid leak, cochlear implant, alcohol use disorder, chronic liver disease,
cigarette smoking, hemoglobinopathy (including sickle cell disease), etc.
 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
given less than ten years before the patient turns 65 years old, in which case
patients should be revaccinated ten years following the first dose.
Recommendations are that patients with functional or anatomic asplenia or
immunocompromised individuals receive repeat doses of the vaccination
every ten years after the first dose.
 Option B: The vaccines have no effect on bronchodilation or respiratory care.
Both vaccines promote active immunization against the serotypes of the
conjugate and capsular polysaccharides contained in the formulation of the
vaccine. Immunity develops approximately 2 to 3 weeks after vaccination and
 lasts for five years. In children and the elderly, re-immunization may be
necessary sooner.
 Option C: Studies done on animals have not shown fetal adverse effects or
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
women. There is no overdose risk with the administration of the vaccine.
13. 13. Question
Exercise has which of the following effects on clients with asthma, chronic bronchitis, and
emphysema?
o A. It enhances cardiovascular fitness.
o B. It improves respiratory muscle strength.
o C. It reduces the number of acute attacks.
o D. It worsens respiratory function and is discouraged.
Correct
Correct Answer: A. It enhances cardiovascular fitness.
Exercise can improve cardiovascular fitness and help the client tolerate periods of hypoxia
better, perhaps reducing the risk of heart attack. People with long-term lung conditions can
help improve their symptoms through regular exercise. It can be tempting to avoid exercise
because 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 B: Most exercise has little effect on respiratory muscle strength, and
these clients can’t tolerate the type of exercise necessary to do this.
Intermittent exercises can help deal with shortness of breath. In this case, the
client alternates brief exercise, lasting 1–2 minutes, with moments of rest (or
slower exercise). This is called interval training.
 Option C: Exercise won’t reduce the number of acute attacks. Having asthma
should not restrict the ability to exercise or be physically active. If the client
feels uncomfortable during or after exercise, he should ask his doctor to
investigate whether the management of his condition could be improved. In
fact, many athletes have asthma and are able to compete at the highest level
when their condition is well-controlled.
 Option D: In some instances, exercise may be contraindicated, and the client
should check with his physician before starting any exercise program. It is best
to ask the guidance of a doctor or physiotherapist before one begins
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
body to adapt.
14. 14. Question
Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following
reasons best explains why?
o A. Reducing fluid volume reduces oxygen demand.
o B. Reducing fluid volume improves clients’ mobility.
o C. Restricting fluid volume reduces sputum production.
o D. Reducing fluid volume improves respiratory function.
Incorrect
Correct Answer: A. Reducing fluid volume reduces oxygen demand.
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 exercise tolerance will still be harder to clear airways. As a result, diuretic drugs
may be prescribed in COPD for a variety of reasons: pulmonary hypertension and cor
pulmonale; pulmonary edema; systemic hypertension; and empirically for severe dyspnoea
refractory to maximal conventional therapy.
 Option B: Diuretic drugs may theoretically improve respiratory health
outcomes in COPD through several possible mechanisms. Diuretics may
reduce pulmonary hypertension (either subclinical or overt) and cor pulmonale
by decreasing preload to the heart and they can also reduce pulmonary edema.
The presence of pulmonary hypertension in COPD is associated with
increased mortality risk 6 and symptoms related to excessive fluid overload
may lead an individual with COPD to present to hospital for acute care
 Option C: Diuretic drugs may theoretically improve respiratory health
outcomes among individuals with chronic obstructive pulmonary disease
(COPD), but they may also contribute to respiratory harm. There are minimal
and conflicting data regarding the potential respiratory effects of systemic
diuretic drugs among individuals with COPD.
 Option D: Reducing fluid volume won’t improve respiratory function but may
improve oxygenation. Acetazolamide inhibits the renal carbonic anhydrase
enzyme, which reduces serum bicarbonate and contributes to metabolic
acidosis, which in turn increases minute ventilation through peripheral and
central chemoreceptor stimulation. By stimulating minute ventilation and
improving gas exchange, acetazolamide may mitigate dyspnoea crises and
respiratory exacerbations among individuals with COPD.
15. 15. Question
A 69-year-old client appears thin and cachectic. He’s short of breath at rest and his dyspnea
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 A. ARDS
o B. Asthma
 o C. Chronic obstructive bronchitis
o D. Emphysema
Correct
Correct Answer: D. Emphysema
In emphysema, the wall integrity of the individual air sacs is damaged, reducing the surface
area available for gas exchange. Very little air movement occurs in the lungs because of
bronchial collapse, as well. In the early stages of the disease, the physical examination may
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
prevents airway collapse during respiration, and the use of accessory muscles of respiration
indicates advanced disease.
 Option A: In ARDS, the client’s condition is more acute and typically requires
mechanical ventilation. Clients with ARDS are acutely short of breath and
require emergency care. The physical examination will include findings
associated with the respiratory system, such as tachypnea and increased effort
to breathe. Systemic signs may also be evident depending on the severity of
illness, such as central or peripheral cyanosis resulting from hypoxemia,
tachycardia, and altered mental status. Despite 100% oxygen, patients have
low oxygen saturation.
 Option B: In asthma, wheezing is prevalent. 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: 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
episodes occurring for 2 years in a row. A productive cough with sputum is
present in about 50% of patients.
16. 16. Question
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?
o A. The client doesn’t notice he needs to breathe.
o B. The client breathes only when his oxygen levels climb above a certain
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.
Incorrect
Correct Answer: C. The client breathes only when his oxygen levels dip below a certain
point.
Clients with emphysema breathe when their oxygen levels drop to a certain level; this is
known as the hypoxic drive. In the meantime, his carbon dioxide levels continue to climb,
and the client will pass out, leading to a respiratory arrest. The hypoxic drive theory then goes
on to say that if the healthcare provider gives these patients too much oxygen they blunt their
hypoxic drive. As their chemoreceptors are already tolerant of high levels of carbon dioxide,
and therefore they have also lost that drive, their respirations will begin to slow causing a
further rise in carbon dioxide levels, and a consequent acidosis.
 Option A: They don’t take a breath when their levels of carbon dioxide are
higher than normal, as do those with healthy respiratory physiology. COPD
patients tend to have chronically elevated levels of carbon dioxide due to the
nature of their illness. The theory goes then that because of this chronically
elevated level of carbon dioxide in the chemoreceptors become tolerant of
these high levels and therefore the carbon dioxide ceases to be that person’s
drive to breathe. What therefore drives them to breathe is the hypoxic drive or
the lower levels of oxygen.
 Option B: If too much oxygen is given, the client has little stimulus to take
another breath. The peripheral chemoreceptors are sensitive to the levels of
oxygen in the body. They will send a signal to breathe when the partial
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.
 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
the drive to breathe to blow off the excess carbon dioxide. So the levels of
carbon dioxide dictate how fast we will breathe.
17. 17. Question
Teaching for a client with chronic obstructive pulmonary disease (COPD) should include
which of the following topics?
o A. How to have his wife learn to listen to his lungs with a stethoscope from
Wal-Mart.
o B. How to increase his oxygen therapy.
o C. How to treat respiratory infections without going to the physician.
o D. How to recognize the signs of an impending respiratory infection.
Correct
Correct Answer: D. How to recognize the signs of an impending respiratory infection.
Respiratory infection in clients with a respiratory disorder can be fatal. It’s important that the
client understands how to recognize the signs and symptoms of an impending respiratory
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 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 following: increased wheezing, increased cough, fever without another cause,
upper respiratory infection within 5 days, or an increase in heart rate or respiratory rate from
the patient’s baseline.
 Option A: It isn’t appropriate for the wife to listen to his lung sounds, besides,
you can’t purchase stethoscopes from Wal-Mart. COPD will typically present
in adulthood and often during the winter months. Patients usually present with
complaints of chronic and progressive dyspnea, cough, and sputum
production. Patients may also have wheezing and chest tightness.
 Option B: Hospitalized patients often require oxygen and bronchodilator
therapy in the form of a SABA with or without a SAMA. Oxygen therapy can
range from a nasal cannula to mechanical ventilation depending on the
severity of the exacerbation. Pulmonary rehabilitation plays a large role in
improving outcomes. Rehabilitation has been shown to improve the quality of
life, dyspnea, and exercise capacity in patients with COPD.
 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
by the presence of 2 or all 3 of the symptoms respectively. Patients may have
acute respiratory failure and physical findings of hypoxemia and hypercapnia.
Arterial blood gas analysis, chest imaging, and pulse oximetry are indicated.
18. 18. Question
Which of the following respiratory disorders is most common in the first 24 to 48 hours after
surgery?
o A. Atelectasis
o B. Bronchitis
o C. Pneumonia
o D. Pneumothorax
Correct
Correct Answer: A. Atelectasis
Atelectasis develops when there’s interference with the normal negative pressure that
promotes lung expansion. Clients in the postoperative phase often splint their breathing
because of pain and positioning, which causes hypoxia. Postoperative atelectasis typically
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
inhibited by general anesthesia due to diaphragm relaxation. Patients lying supine have
cephalad displacement of the diaphragm further decreasing the transmural pressure gradient
and increasing the likelihood of atelectasis. It’s uncommon for any of the other respiratory
disorders to develop.
 Option B: Acute bronchitis is caused by infection of the large airways
commonly due to viruses and is usually self-limiting. Bacterial infection is
uncommon. Approximately 95% of acute bronchitis in healthy adults is
secondary to viruses. It can sometimes be caused by allergens, irritants, and
bacteria. Irritants include smoke inhalation, polluted air inhalation, dust,
among others.
 Option C: While identifying an etiologic agent for pneumonia is essential for
effective treatment as well as epidemiological record keeping, this is seldom
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
to the emergency department.
 Option D: A pneumothorax is defined as a collection of air outside the lung
but within the pleural cavity. It occurs when air accumulates between the
parietal and visceral pleura inside the chest. The air accumulation can apply
pressure on the lung and make it collapse. The degree of collapse determines
the clinical presentation of pneumothorax. Air can enter the pleural space by
two mechanisms, either by trauma causing a communication through the chest
wall or from the lung by rupture of visceral pleura.
19. 19. Question
Which of the following measures can reduce or prevent the incidence of atelectasis in a
postoperative client?
o A. Chest physiotherapy
o B. Mechanical ventilation
o C. Reducing oxygen requirements
o D. Use of an incentive spirometer.
Correct
Correct Answer: D. Use of an incentive spirometer.
Using an incentive spirometer requires the client to take deep breaths and promotes lung
expansion. Incentive spirometry is designed to mimic natural sighing or yawning by
encouraging the patient to take long, slow, deep breaths. This decreases pleural pressure,
promoting increased lung expansion and better gas exchange. When the procedure is repeated
on a regular basis, atelectasis may be prevented or reversed.
 Option A: Chest physiotherapy helps mobilize secretions but won’t prevent
atelectasis. Techniques that help the client breathe deeply after surgery to re-
expand collapsed lung tissue are very important. These techniques are best
learned before surgery. Positioning the body so that the head is lower than the
 chest (postural drainage). This allows mucus to drain better from the bottom of
the lungs.
 Option B: Reducing oxygen requirements doesn’t affect the development of
atelectasis. Removal of airway obstructions may be done by suctioning mucus
or by bronchoscopy. During bronchoscopy, the doctor gently guides a flexible
tube down the throat to clear the airways.
 Option C: Placing someone on mechanical ventilation doesn’t improve
atelectasis. Continuous positive airway pressure (CPAP) may be helpful in
some people who are too weak to cough and have low oxygen levels
(hypoxemia) after surgery.
20. 20. Question
Emergency treatment of a client in status asthmaticus includes which of the following
medications?
o A. Inhaled beta-adrenergic agents
o B. Inhaled corticosteroids
o C. I.V. beta-adrenergic agents
o D. Oral corticosteroids
Correct
Correct Answer: A. Inhaled beta-adrenergic agents
Inhaled beta-adrenergic agents help promote bronchodilation, which improves oxygenation.
Albuterol is preferred over metaproterenol in that class because of its higher beta 2
selectivities and longer duration of action. The dose-response curve and duration of action of
these medications are adversely affected by a combination of patient factors, including pre-
existing bronchoconstriction, airway inflammation, mucus plugging, poor patient effort, and
coordination.
 Option B: Inhaled corticosteroids have potent glucocorticoid activity and
work directly at the cellular level by reversing capillary permeability and
lysosomal stabilization to reduce inflammation. The onset of action is gradual
and may take anywhere from several days to several weeks for maximal
benefit with consistent use. Metabolism is through the hepatic route, with a
half-life elimination of up to 24 hours.
 Option C: I.V. beta-adrenergic agents can be used but have to be monitored
because of their greater systemic effects. They’re typically used when the
inhaled beta-adrenergic agents don’t work. Intravenous beta-agonists are not
routinely recommended, although there are reports of center-specific use in
younger patients with status asthmaticus, nonresponsive to inhaled therapy
demonstrating persistent severe hyperinflation of airways.
 Option D: Corticosteroids are slow-acting, so their use won’t reduce hypoxia
in the acute phase. At a physiologic level, steroids reduce airway inflammation
 and mucus production and potentiate beta-agonist activity in smooth muscles
and reduce beta-agonists tachyphylaxis in patients with severe asthma.
21. 21. Question
Which of the following treatment goals is best for the client with status asthmaticus?
o A. Avoiding intubation.
o B. Determining the cause of the attack.
o C. Improving exercise tolerance.
o D. Reducing secretions.
Correct
Correct Answer: A. Avoiding intubation
Inhaled beta-adrenergic agents, I.V. corticosteroids, and supplemental oxygen are used to
reduce bronchospasm, improve oxygenation, and avoid intubation. A favorable response to
initial treatment of status asthmaticus should be a visible improvement in symptoms that
sustains 30 minutes or beyond the last bronchodilator dose and a PEFR greater than 70% of
predicted.
 Option B: Determining the trigger for the client’s attack is a later goal. Eighty
percent to 85% of asthma fatalities are in the subgroup of slow-onset asthma
exacerbation, perhaps reflecting an inadequate disease control over time. In
contrast to the sudden onset of exacerbation phenotype, which presents mostly
with clear airways, slow-onset exacerbation patients have extensive airway
inflammation and mucus plugging.
 Option C: Status asthmaticus can be prevented if triggers and stress factors
are avoided, and compliance with the medicines is good. Identify those
individuals who are at a greater risk of exacerbation, such as extremes of ages.
Environmental management is essential in patients with environmental
allergies. Inpatient education by trained lay people resulted in improvement in
compliance with inhaler management and post-discharge care.
 Option D: Typically, secretions aren’t a problem in status asthmaticus.
Albuterol is preferred over metaproterenol in that class because of its higher
beta 2 selectivities and longer duration of action. The dose-response curve and
duration of action of these medications are adversely affected by a
combination of patient factors, including pre-existing bronchoconstriction,
airway inflammation, mucus plugging, poor patient effort, and coordination.
22. 22. Question
Dani was given Dilaudid for pain. She’s sleeping and her respiratory rate is 4 breaths/minute.
If action isn’t taken quickly, she might have which of the following reactions?
o A. Asthma attack
o B. Respiratory arrest
 o C. Improve cardiac output
o D. Constipation
Correct
Correct Answer: B. Respiratory arrest
Narcotics can cause respiratory arrest if given in large quantities. Threatening life events are
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
refractory pain. Concurrent use of hydromorphone with other CNS depressants, including
benzodiazepine and barbiturates, can induce severe respiratory and/or CNS depression. For
this purpose, the use of alternative analgesic agents is necessary.
 Option A: Asthma comprises a range of diseases and has a variety of
heterogeneous phenotypes. The recognized factors that are associated with
asthma are a genetic predisposition, specifically a personal or family history of
atopy (propensity to allergy, usually seen as eczema, hay fever, and asthma).
 Option C: Hydromorphone is a rapid-acting potent opioid used in acute and
chronic pain. It is interchangeable with other opioids and has a specific
conversion scale. Hydromorphone is available in multiple forms, including
injection and oral forms, immediate-release, and extended-release forms. The
risk profile of this drug requires careful prescription and administration, with
thorough knowledge of the potential harms and interactions.
 Option D: Hydromorphone is to be avoided in any gastrointestinal obstruction
or hypomotility, including ileus. Postoperative ileus should prompt careful
administration of hydromorphone, to prevent prolonged ileus.
23. 23. Question
Which of the following additional assessment data should immediately be gathered to
determine the status of a client with a respiratory rate of 4 breaths/minute?
o A. Arterial blood gas (ABG) and breath sounds.
o B. Level of consciousness and a pulse oximetry value.
o C. Breath sounds and reflexes.
o D. Pulse oximetry value and heart sounds.
Correct
Correct Answer: B. Level of consciousness and a pulse oximetry value.
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
should be checked. The physician should be notified immediately of the findings. The care of
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.
  Option A: He’ll probably order ABG analysis to determine specific carbon
dioxide and oxygen levels, which will indicate the effectiveness of ventilation.
If the physician suspects that the individual has overdosed on an opiate and
has signs of respiratory and CNS depression, no time should be wasted on
laboratory studies; instead, naloxone should be administered as soon as
possible.
 Option C: Reflexes and heart sounds will be part of the more extensive
examination done after these initial actions are completed. An ECG is
recommended in all patients with suspected opioid overdose. Coingestants like
tricyclics have the potential to cause arrhythmias.
 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,
airway control has been obtained by emergency medical personnel at the
scene, but if there is any sign of respiratory distress or failure to protect the
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
unknown cause of lethargy or loss of consciousness have their blood glucose
levels drawn.
24. 24. Question
A client is in danger of respiratory arrest following the administration of a narcotic analgesic.
An arterial blood gas value is obtained. The nurse would expect PaCO2 to be which of the
following values?
o A. 15 mm Hg
o B. 30 mm Hg
o C. 40 mm Hg
o D. 80 mm Hg
Correct
Correct Answer: D. 80 mm Hg
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 than expected. When shunt is predominant above other mechanisms, the hypoxemia
is more severe and refractory to oxygen therapy, meaning that high levels of inspiratory
oxygen fraction (FIO2 >50-60%) are needed to reach PaO2 values between 60 and 70mmHg,
as in ARDS.
 Option A: In cases of significant alveolar dead space (large areas of
pulmonary parenchyma without perfusion), such as in pulmonary emphysema,
there may be both hypoxemia and hypercapnia due to alveolar hypoventilation
and V/Q mismatch, especially if the ventilatory pump could not compensate
the baseline disturb.
  Option B: The hypoxic ARF is defined by PaO2 levels < 55-60mmHg, in-
room air or with indication for oxygen therapy with no CO2 retention. The
pulmonary causes of hypoxemia or hypercapnia include dead space,
impairment of gas 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 V/Q disorders may coexist in the patient’s
pulmonary parenchyma.
 Option C: The hypercapnic ARF is characterized by increased PaCO2 levels
above 45-50mHg with resultant acidemia; pH<7.34. The hypercapnic ARF is
invariably associated with alveolar hypoventilation with resulting in mild
hypoxemia. In the hypoxemic type, however, the main alteration is the
increased D(A-a)O2 caused by the pulmonary parenchyma disease and
ventilation/perfusion (V/Q) mismatch.
25. 25. Question
A client has started a new drug for hypertension. Thirty minutes after he takes the drug, he
develops chest tightness and becomes short of breath and tachypnea. He has a decreased level
of consciousness. These signs indicate which of the following conditions?
o A. Asthma attack
o B. Pulmonary embolism
o C. Respiratory failure
o D. Rheumatoid arthritis
Incorrect
Correct Answer: C. Respiratory Failure
The client was reacting to the drug with respiratory signs of impending anaphylaxis, which
could 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 lower than 60 mmHg and/or PaCO2 higher than 50 mmHg.
 Option A: Although the signs are also related to an asthma attack, consider
the new drug first. The overall etiology is complex and still not fully
understood, especially when it comes to being able to say which children with
pediatric asthma will carry on to have asthma as adults (up to 40% of children
have a wheeze, only 1% of adults have asthma), but it is agreed that it is a
multifactorial pathology, influenced by both genetics and environmental
exposure.
 Option B: Most pulmonary embolisms originate as lower extremity DVTs.
Hence, risk factors for pulmonary embolism (PE) are the same as risk factors
for DVT. Virchow’s triad of hypercoagulability, venous stasis, and endothelial
injury provides an understanding of these risk factors.
  Option D: Rheumatoid arthritis doesn’t manifest these signs. Most common
clinical presentation of RA is polyarthritis of small joints of hands: proximal
interphalangeal (PIP), metacarpophalangeal (MCP) joints, and wrist. Some
patients may present with monoarticular joint involvement.
26. 26. Question
Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity
to a drug should include which of the following actions first?
o A. Administering oxygen.
o B. Inserting an I.V. catheter.
o C. Obtaining a complete blood count (CBC).
o D. Taking vital signs.
Correct
Correct Answer: A. Administering oxygen.
Giving oxygen would be the best first action in this case. Airway management is paramount.
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 airway is imperative. Delay may reduce the chances of successful intubation as
continued swelling occurs, increasing the risk for a surgical airway.
 Option B: If the client doesn’t already have an I.V. catheter, one may be
inserted now if anaphylactic shock is developing. Anaphylaxis induces a
distributive shock that typically is responsive to fluid resuscitation and the
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 not indicated.
 Option C: Obtaining a CBC wouldn’t help the emergency situation.
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
elevation and late presentation. Serum tryptase can be considered for
confirmation of an anaphylactic episode as it remains elevated for several
hours, however, as a diagnostic modality, this has low sensitivity.
 Option D: Vital signs then should be checked and the physician immediately
notified. Anaphylaxis is most often a rapidly evolving presentation, usually
within one hour of exposure. Roughly half of the anaphylactic-related
fatalities 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 rapid the onset and progression of symptoms, the more severe the
disease process.
27. 27. Question
Following the initial care of a client with asthma and impending anaphylaxis from
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.
Incorrect
Correct Answer: B. Administer bronchodilators.
Bronchodilators would help open the client’s airway and improve his oxygenation status.
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
inhaled beta-agonists are the first-line treatment in wheezing; albuterol alone or as
ipratropium bromide/albuterol. If there is refractory wheezing IV magnesium is appropriate
with dosage and treatment similar to severe asthma exacerbations.
 Option A: Beta-adrenergic blockers aren’t indicated in the management of
asthma because they may cause bronchospasm. Corticosteroids are given for
the reduction of length or biphasic response of anaphylaxis. There is minimal
literature to support this use specifically in anaphylaxis, but it has been proven
effective in reactive airway diseases. Therefore, use, dosages, and proposed
mechanism of action mimic those of airway management protocols.
 Option C: Obtaining laboratory values wouldn’t be done on an emergency
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
elevation and late presentation. Serum tryptase can be considered for
confirmation of an anaphylactic episode as it remains elevated for several
hours, however, as a diagnostic modality, this has low sensitivity.
 Option D: Having the client lie flat in bed could worsen his ability to breathe.
Airway management is paramount. 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 airway is
imperative. Delay may reduce the chances of successful intubation as
continued swelling occurs, increasing the risk for a surgical airway.
28. 28. Question
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. Metabolic acidosis
o B. Metabolic alkalosis
o C. Respiratory acidosis
 o D. Respiratory alkalosis
Correct
Correct Answer: C. Respiratory acidosis
PaCO2 > 40 with a pH < 7.4 indicates a respiratory acidosis. If the pH is in the normal range
(7.35-7.45), use a pH of 7.40 as a cutoff point. In other words, a pH of 7.37 would be
categorized as acidosis. Arterial blood gas interpretation is best approached systematically.
Interpretation leads to an understanding of the degree or severity of abnormalities, whether
the abnormalities are acute or chronic, and if the primary disorder is metabolic or respiratory
in origin.
 Option A: Evaluate the respiratory and metabolic components of the ABG
results, the PaCO2 and HCO3, respectively. The PaCO2 indicates whether the
acidosis or alkalemia is primarily from a respiratory or metabolic
acidosis/alkalosis.
 Option B: The acid-base that is inconsistent with the pH is the HCO3, as it is
elevated, indicating a metabolic alkalosis, so there is compensation signifying
a non-acute primary disorder because it takes days for metabolic compensation
to be effective.
 Option D: PaCO2 < 40 and pH < 7.4 indicates a respiratory alkalosis (but is
often from hyperventilation from anxiety or compensation for a metabolic
acidosis). Assess for evidence of compensation for the primary acidosis or
alkalosis by looking for the value (PaCO2 or HCO3) that is not consistent with
the pH.
29. 29. 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?
o A. Respiratory acidosis
o B. Respiratory alkalosis
o C. Metabolic acidosis
o D. Metabolic alkalosis
Correct
Correct Answer: A. 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
collapse, air trapping, and disturbance of ventilation-perfusion relationships. Respiratory
acidosis is a state in which there is usually a failure of ventilation and an accumulation of
carbon dioxide. The primary disturbance of elevated arterial PCO2 is the decreased ratio of
arterial bicarbonate to arterial PCO2, which leads to a lowering of the pH.
  Option B: Respiratory alkalosis may be an acute process or a chronic process.
These are determined based on the level of metabolic compensation for the
respiratory disease. Acute respiratory alkalosis is associated with high
bicarbonate levels since there has not been sufficient time to lower the HCO3
levels and chronic respiratory alkalosis is associated with low to normal
HCO3 levels.
 Option C: Metabolic acidosis is characterized by an increase in the hydrogen
ion concentration in the systemic circulation resulting in a serum HCO3 less
than 24 mEq/L. Metabolic acidosis is not a benign condition and signifies an
underlying disorder that needs to be corrected to minimize morbidity and
mortality.
 Option D: Normal human physiological pH is 7.35 to 7.45. A decrease in pH
below this range is acidosis, an increase over this range is alkalosis. Metabolic
alkalosis is defined as a disease state where the body’s pH is elevated to
greater than 7.45 secondary to some metabolic process.
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.