The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). The client's ABG reveals: pH 7.59, PaCO2 29 mmHg, Pa02 55 mmHg, HCO3 22 mEq/L, and 02 saturation 72%. What would be the expected assessment finding?

Table 9.9 Normal Arterial Blood Gas Values

ABG Value.                                                             Normal Value

pH                                                                             7.35-7.45

PaCO2                                                                                                            35-45 mmHg

HCO3-                                                                         22-26mEq/L

Base excess                                                               -2 to +2

PaO2                                                                            80-95 mmHg

SaO2                                                                            >95%

respiratory rate of 10 breaths per minute.

respiratory rate of 32 breaths per minute.

blood pressure 86/42 mmHg.

heart rate of 45 beats per minute.

Answer and Explanation

The Correct Answer is B

Explanation of each option:

A. Respiratory rate of 10 breaths per minute:
A respiratory rate of 10 breaths per minute would be too slow in a patient with ARDS and hypoxemia. In response to hypoxemia, the body typically increases the respiratory rate to improve oxygenation. A respiratory rate of 10 breaths per minute would not be expected in this situation.

B. Respiratory rate of 32 breaths per minute: The arterial blood gas (ABG) results indicate respiratory alkalosis with hypoxemia, which is a common finding in patients with acute respiratory distress syndrome (ARDS). pH 7.59: This is alkalotic, meaning the body is experiencing respiratory alkalosis.

PaCO2 29 mmHg: The PaCO2 is low, indicating hyperventilation, which is a compensatory response to the alkalosis in an attempt to reduce carbon dioxide levels.

PaO2 55 mmHg: This is severely low, indicating hypoxemia (low oxygen levels in the blood), a hallmark of ARDS. HCO3 22 mEq/L: The bicarbonate is normal, suggesting that the metabolic component has not yet compensated for the respiratory alkalosis, or that it is in the early stages of compensation. Given these ABG results, the body is attempting to compensate for hypoxemia by increasing respiratory rate (tachypnea), which leads to hyperventilation and further reduction in PaCO2. Therefore, an expected assessment finding in this scenario would be a high respiratory rate (such as 32 breaths per minute), which is a compensatory response to hypoxemia.

C. Blood pressure 86/42 mmHg:
While hypotension can occur in severe cases of ARDS due to impaired oxygenation and circulation, it is not directly reflected by the ABG results provided. Hypoxemia and alkalosis would more likely lead to tachypnea and compensatory mechanisms like tachycardia, rather than significant hypotension unless there is another contributing factor, such as shock or sepsis. Therefore, hypotension is not the most expected finding based on these ABGs.

D. Heart rate of 45 beats per minute:
A heart rate of 45 beats per minute is bradycardic, which would be unusual in a patient with hypoxemia and respiratory alkalosis. Tachycardia is a more common compensatory response to hypoxia, as the heart works harder to improve oxygen delivery to tissues. A heart rate of 45 beats per minute would be more suggestive of a different underlying condition, such as vagal stimulation or cardiac conduction issues, but it is not the expected response in this case.

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Correct Answer is D

Explanation

A. Similar to the angina attacks you had in the past:
This response is not entirely accurate. Angina refers to chest pain that occurs when the heart's demand for oxygen exceeds its supply, usually due to partial blockage of the coronary arteries. NSTEMI (non-ST elevation myocardial infarction) is different from angina in that it involves actual heart muscle injury or damage due to partial or intermittent blockage of a coronary artery, whereas angina does not cause permanent heart muscle damage. Therefore, describing NSTEMI as similar to past angina attacks would be misleading.

B. A condition characterized by coronary arteries vasodilating:
This is incorrect. NSTEMI occurs due to a partial blockage or narrowing of the coronary arteries, usually caused by a blood clot that forms around a ruptured atherosclerotic plaque. The blockage restricts blood flow to the heart muscle, causing injury or infarction. Vasodilation (the widening of blood vessels) is not a characteristic of NSTEMI; in fact, it is the constriction or blockage of the coronary arteries that leads to this type of heart attack.

C. A term used to describe an irregular heartbeat:
This is incorrect. NSTEMI is not related to an irregular heartbeat or arrhythmia directly. While arrhythmias (irregular heartbeats) can occur as a result of a heart attack, NSTEMI specifically refers to a type of heart attack that is not accompanied by the characteristic ST-segment elevation seen on an electrocardiogram (ECG) in a STEMI (ST-elevation myocardial infarction). It indicates a partial blockage of a coronary artery and is generally less severe than STEMI.

D. Is a less severe type of heart attack compared to STEMI:
This is the most accurate response. NSTEMI is a type of heart attack that is often considered less severe than STEMI, but still involves heart muscle injury. The difference between NSTEMI and STEMI lies in the ECG findings: STEMI involves a full-thickness myocardial infarction with a significant blockage of the artery, as indicated by ST-segment elevation on an ECG. In NSTEMI, there is a partial blockage or temporary decrease in blood flow, and the ST-segment does not elevate on the ECG, but biomarkers (like troponin) are elevated, indicating heart muscle damage. NSTEMI is often less severe in terms of the extent of damage compared to STEMI, but it still requires urgent treatment to prevent further complications.

A. remove the BIPAP mask. B. Assist the client to a side lying position. C. administer ondansetron intravenously (IV). D. notify the primary care provider.

Correct Answer is B

Explanation

A. Remove the BIPAP mask:
While removing the BIPAP mask may seem like a reasonable action to take in response to vomiting, it is not the immediate priority. The most urgent issue in this scenario is preventing aspiration and maintaining the client’s airway. Removing the mask may be necessary later for resuscitation or further interventions, but the first priority is protecting the airway and preventing aspiration pneumonia, which is best done by positioning the client appropriately. BIPAP should only be removed if the client's airway cannot be maintained, or if there is a need for intubation or other advanced airway management.

B. Assist the client to a side-lying position: When a client on BIPAP (bi-level positive airway pressure) begins to vomit, the priority nursing intervention is to protect the airway and prevent aspiration. The side-lying position is the most effective way to prevent aspiration of vomit into the lungs, as it allows the contents to drain from the mouth and reduces the risk of airway obstruction. This position also ensures that the client’s airway remains open while minimizing the risk of choking or aspiration pneumonia. The side-lying position is crucial in managing nausea and vomiting in clients on non-invasive ventilation, like BIPAP.

C. Administer ondansetron intravenously (IV):
Ondansetron is an effective antiemetic and may be appropriate to administer if the client’s nausea continues. However, nausea and vomiting are secondary concerns in this situation compared to airway protection. The first priority is to position the client to prevent aspiration of vomit. Once the client is in a safe position, ondansetron may be administered to address the nausea and prevent further vomiting, but this does not address the immediate airway risk.

D. Notify the primary care provider:
While notifying the healthcare provider may be necessary at some point, the priority nursing intervention is to manage the immediate concern of the client vomiting while on BIPAP. The primary concern at this point is protecting the airway and preventing aspiration. The healthcare provider may need to be informed about the situation, but the nurse must first ensure the client's safety through appropriate positioning.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

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Naxlex Comprehensive Predictor Exams

The client tells the nurse, "My physician told me that I had a non-ST elevation myocardial infarction (NSTEMI). " I thought all heart attacks were the same. Can you explain this to me?" The nurse's best response to the client's question would be: "NSTEMI is

Correct Answer is D

Explanation

The nurse is caring for a client with acute respiratory failure who has been placed on bi-level positive airway pressure (BIPAP) for adequate ventilation. The client complains of nausea and begins to vomit. The priority nursing intervention would be:

Correct Answer is B

Explanation

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