A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Headache

Severe dyspnea

Nausea

Hypotension

Answer and Explanation

Correct Answer : B,D,E

Choice A Reason: This choice is incorrect because headache is not a common manifestation of ARF. Headache may be caused by various factors such as dehydration, stress, sinusitis, or migraine, but it does not indicate ARF.

Choice B Reason: This choice is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a difficulty or discomfort in breathing that aﬀects the oxygen delivery and carbon dioxide removal from the body. It may be caused by various factors such as lung disease, heart disease, anemia, or anxiety, but it indicates ARF when it is severe and persistent.

Choice C Reason: This choice is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of uneasiness or discomfort in the stomach that may precede vomiting. It may be caused by various factors such as food poisoning, motion sickness, medication side eﬀects, or pregnancy, but it does not indicate ARF.

Choice D Reason: This choice is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal (less than 90/60 mm Hg). It may be caused by various factors such as dehydration, blood loss, sepsis, or shock, but it indicates ARF when it is due to reduced cardiac output or vasodilation from hypoxia.

Choice E Reason: This choice is correct because decreased level of consciousness is a common manifestation of ARF. Decreased level of consciousness is a condition in which the person has impaired awareness or responsiveness to stimuli. It may be caused by various factors such as brain injury, stroke, seizure, or drug overdose, but it indicates ARF when it is due to increased carbon dioxide levels (hypercapnia) or decreased oxygen levels (hypoxemia) in the brain.

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Correct Answer is D

Explanation

Choice A Reason: This choice is incorrect because providing a brightly lit environment may stimulate the client and increase the intracranial pressure. A brightly lit environment is an environment that has a high level of illumination or brightness. It may be used for clients who have depression, seasonal aﬀective disorder, or insomnia, but it does not help to reduce the intracranial pressure.

Choice B Reason: This choice is incorrect because teaching controlled coughing and deep breathing may increase the intrathoracic pressure and increase the intracranial pressure. Controlled coughing and deep breathing are techniques that help to clear the airway and improve lung expansion. They may be used for clients who have respiratory infections, chronic obstructive pulmonary disease, or postoperative complications, but they do not help to reduce the intracranial pressure.

Choice C Reason: This choice is incorrect because encouraging a minimum intake of 2000 mL (67.5 oz) of clear ﬂuids per day may cause ﬂuid overload and increase the intracranial pressure. Fluid overload is a condition in which the body has too much ﬂuid, which can impair the function of the heart, lungs, and kidneys. Therefore, restricting ﬂuid intake and using diuretics may be indicated for clients who have increased intracranial pressure.

Choice D Reason: This choice is correct because elevating the head of the bed 20° may help to improve the venous drainage and decrease the intracranial pressure. As explained above, positioning the client in a semi-Fowler's or high-Fowler's position can facilitate breathing and prevent further complications. However, elevating the head of the bed more than 30° may decrease the cerebral perfusion pressure (CPP), which is the diﬀerence between the mean arterial pressure (MAP) and the intracranial pressure (ICP). A normal CPP range is 70 to 100 mm Hg, and a low CPP (<50 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, elevating the head of the bed to a moderate angle (20°) may be optimal for clients who have increased ICP.

A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Correct Answer is A

Explanation

Choice A Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client has impaired ventilation and excess carbon dioxide in the blood.

Choice B Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client has increased ventilation and reduced carbon dioxide in the blood.

Choice C Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low HCO3, indicating that the client has an excess of metabolic acids or a loss of base in the blood.

Choice D Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high HCO3, indicating that the client has an excess of base or a loss of metabolic acids in the blood.

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A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 is 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base imbalances?

Correct Answer is A

Explanation

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