Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials "911" because Anne is unconscious, has depressed ventilation (shallow and slow respirations), rapid heart rate, and is bleeding from both ears.
Which primary acid-base imbalance is Anne at risk for if medical attention is not provided?

Respiratory Alkalosis.

Metabolic Alkalosis.

Respiratory Acidosis.

Metabolic Acidosis.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Respiratory alkalosis occurs due to hyperventilation, leading to excessive carbon dioxide expulsion. This reduces the partial pressure of carbon dioxide ($PaCO_2$), increasing the pH. Anne's depressed ventilation indicates hypoventilation, not hyperventilation, which would cause an accumulation of $CO_2$ rather than its expulsion. Therefore, respiratory alkalosis is not the primary imbalance she faces.

Choice B rationale

Metabolic alkalosis arises from an excess of bicarbonate ($HCO_3^-$) or a loss of hydrogen ions ($H^+$), typically from vomiting or diuretics. This increases the pH. Anne's symptoms of depressed ventilation and head trauma do not directly point to a primary metabolic issue causing $HCO_3^-$ retention or $H^+$ loss; her immediate risk is respiratory compromise.

Choice C rationale

Respiratory acidosis develops when the lungs cannot adequately remove carbon dioxide ($CO_2$), leading to its accumulation in the blood. This accumulation increases carbonic acid, which lowers the pH. Anne's depressed ventilation (shallow and slow respirations) directly impairs $CO_2$ excretion, causing $CO_2$ retention and a decrease in blood pH, thus predisposing her to respiratory acidosis. Normal $PaCO_2$ range is 35-45 mmHg.

Choice D rationale

Metabolic acidosis results from an accumulation of non-carbonic acids or a loss of bicarbonate ($HCO_3^-$). This lowers the pH. While head trauma can sometimes lead to metabolic derangements, Anne's immediate and primary physiological compromise is depressed ventilation, which directly affects $CO_2$ elimination and respiratory acid-base balance rather than metabolic acid accumulation or bicarbonate loss.

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Correct Answer is A

Explanation

Choice A rationale

Administering oxygen via a high-flow (Non-rebreather) mask is the immediate priority due to the client's hypoxemia, indicated by an SpO2 of 92% on room air. This action directly addresses the life-threatening compromise in oxygenation, increasing the fraction of inspired oxygen (FiO2) and improving tissue perfusion. Adequate oxygenation is critical to prevent further cellular damage and organ dysfunction in an acute respiratory distress scenario. Normal SpO2 is 95-100%.

Choice B rationale

Obtaining a chest X-ray is an important diagnostic step to identify the underlying cause of absent breath sounds, such as a pneumothorax or hemothorax. However, it is not the *first* action because stabilizing the client's oxygenation and ventilation takes precedence. While imaging provides crucial information, delaying oxygen administration to perform an X-ray could worsen the client's respiratory compromise.

Choice C rationale

Preparing for chest tube insertion is a critical intervention for conditions like pneumothorax or hemothorax, which are suggested by absent breath sounds. While this may be necessary, it is a definitive treatment that follows initial stabilization. Ensuring adequate oxygenation and establishing a clear diagnosis are prerequisites before proceeding with an invasive procedure like chest tube insertion.

Choice D rationale

Initiating IV access is essential for fluid resuscitation, medication administration, and emergency interventions. However, in the hierarchy of needs for a client with acute respiratory distress, establishing an airway and ensuring adequate oxygenation are paramount. While IV access should be established promptly, it does not supersede the immediate need to address life-threatening hypoxemia.

A. Position patient sitting on the edge of the bed, leaning on a pillow that is on top of the bedside table. B. Place the patient in prone position and open the back of their gown. C. Have the patient lying supine with arms folded across their chest. D. No particular positioning is required.

Correct Answer is A

Explanation

Choice A rationale

Positioning the patient sitting on the edge of the bed, leaning on a pillow on the bedside table, is the optimal position for a thoracentesis. This position maximizes the intercostal spaces, allowing for easier access to the pleural cavity while keeping the diaphragm in a lowered position. This widens the spaces between the ribs, facilitating needle insertion and minimizing the risk of injury to surrounding structures like the lungs or diaphragm.

Choice B rationale

Placing the patient in a prone position is contraindicated for a thoracentesis. This position would make accessing the posterior pleural space extremely difficult and unsafe, increasing the risk of accidental organ puncture. It offers no anatomical advantage for the procedure and significantly impedes proper visualization and access to the typical insertion site.

Choice C rationale

Lying supine with arms folded across the chest is not an appropriate position for a thoracentesis. This position would flatten the intercostal spaces, making needle insertion more challenging and increasing the risk of lung puncture. It does not provide optimal access to the pleural cavity for fluid drainage and limits respiratory excursion.

Choice D rationale

Stating no particular positioning is required for a thoracentesis is incorrect and potentially dangerous. Proper positioning is critical for patient safety and procedural success, as it optimizes access to the pleural space, minimizes risks, and enhances patient comfort during the procedure. Incorrect positioning can lead to complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Your patient comes into the Emergency Room with a chief complaint of dyspnea which is worse upon inspiration. The patient is diagnosed with a pleural effusion, and the medical doctor wants to do a Thoracentesis. How should you position the patient?

Correct Answer is A

Explanation

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Your patient developed acute respiratory distress and was just emergently intubated. Because of normal human anatomy, you understand that the most common misplacement of tube position is likely to be:

The nurse responding to a high-pressure alarm on the ventilator would assess for which condition?

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