The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Auscultate bilateral breath sounds.

Obtain blood culture for tuberculosis.

Request pulmonary function studies.

Document the findings.

Answer and Explanation

The Correct Answer is A

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

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Correct Answer is A

Explanation

A. Respiratory acidosis.

COPD is a chronic lung disease that can lead to an accumulation of carbon dioxide (CO2) in the body. This can cause respiratory acidosis, a condition in which the blood pH is lower than normal due to an excess of CO2.

In respiratory acidosis, the partial pressure of carbon dioxide (PaCO2) in the blood is increased and the pH is decreased. The kidneys atempt to compensate for the acidosis by excreting more acid in the urine and retaining more bicarbonate, but this compensation is usually not enough to fully correct the problem.

Metabolic alkalosis (option B) is a condition in which the blood pH is higher than normal due to an excess of bicarbonate in the blood. This is usually caused by loss of acid from the body, such as through vomiting or use of diuretics.

Respiratory alkalosis (option C) is a condition in which the blood pH is higher than normal due to a decrease in PaCO2. This can be caused by hyperventilation, which leads to excessive elimination of CO2 from the lungs.

Metabolic acidosis (option D) is a condition in which the blood pH is lower than normal due to an excess of acid in the blood. This can be caused by a variety of factors, including kidney failure or lactic acidosis.

A. pH-7.10. CO2-78. HCO3-25 B. pH-7.55. C02-20. HCO3-24 C. pH-7.25, CO2-64, HCO3-22 D. Ph-7.0. CO2-72. HCO3-26

Correct Answer is B

Explanation

Respiratory alkalosis is a condition in which the blood pH is elevated due to a decrease in the partial pressure of carbon dioxide (CO2) in the blood. This can occur when a person breathes too rapidly or deeply (hyperventilation), causing them to exhale too much CO2. In this option, the pH is elevated (normal range is 7.35-7.45), the CO2 is low (normal range is 35-45 mmHg), and the bicarbonate (HCO3) level is within the normal range (22-26 mEq/L), which are all consistent with respiratory alkalosis.

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The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

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