The nurse is assessing a client with acute heart failure. Which finding would the nurse anticipate?

Warm flushed extremities

Increased urine output

Orthostatic hypotension

Decreased skin turgor

Answer and Explanation

The Correct Answer is C

a. Warm flushed extremities: In acute heart failure, there is typically inadequate cardiac output to perfuse the peripheral tissues adequately. This can lead to vasoconstriction and decreased blood flow to the extremities, resulting in cool and pale or mottled skin rather than warm flushed extremities.

b. Increased urine output: Acute heart failure is characterized by impaired cardiac function, which can lead to decreased cardiac output and reduced renal perfusion. This can result in decreased urine output rather than increased urine output. In acute heart failure, the kidneys may activate compensatory mechanisms such as the renin-angiotensin-aldosterone system, leading to sodium and water retention and decreased urine output.

c. Orthostatic hypotension: Orthostatic hypotension, a drop in blood pressure upon standing, is not typically associated with acute heart failure. Instead, acute heart failure is more commonly associated with signs and symptoms of fluid overload such as peripheral edema, pulmonary congestion, and jugular venous distension.

d. Decreased skin turgor: Decreased skin turgor is not a typical finding in acute heart failure. It is more commonly associated with dehydration or volume depletion rather than acute heart failure, which is characterized by fluid overload.

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Correct Answer is B

Explanation

Based on the expected changes in hyperventilation related to anxiety, option b (pH 7.47, PaCO2 25 mmHg, HCO3 26 mEq/L) is the most consistent with respiratory alkalosis, which occurs due to hyperventilation:

a. pH 7.49, PaCO2 36 mmHg, HCO3 31 mEq/L:

The pH is higher than the normal range, indicating alkalosis.
The PaCO2 is within the normal range (slightly elevated), which is unexpected in hyperventilation where PaCO2 is typically decreased.
The HCO3 is elevated, indicating metabolic alkalosis, which is not typically associated with hyperventilation related to anxiety.

b. pH 7.47, PaCO2 25 mmHg, HCO3 26 mEq/L:

The pH is higher than the normal range, indicating alkalosis.
The PaCO2 is below the normal range, indicating respiratory alkalosis, which is consistent with hyperventilation.
The HCO3 is within the normal range, which can occur as a compensatory mechanism for respiratory alkalosis.

c. pH 7.32, PaCO2 41 mmHg, HCO3 22 mEq/L:

The pH is lower than the normal range, indicating acidosis.
The PaCO2 is within the normal range, which is unexpected in hyperventilation where PaCO2 is typically decreased.
The HCO3 is within the normal range, indicating compensated metabolic acidosis, which is not typically associated with hyperventilation related to anxiety.

d. pH 7.30, PaCO2 48 mmHg, HCO3 26 mEq/L:

The pH is lower than the normal range, indicating acidosis.
The PaCO2 is elevated, indicating respiratory acidosis, which is not typically associated with hyperventilation.
The HCO3 is within the normal range, which can occur as a compensatory mechanism for respiratory acidosis.

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

Correct Answer is A

Explanation

a. Metabolic alkalosis: Metabolic alkalosis can occur due to loss of gastric acid through suctioning of gastric contents via the nasogastric tube. Continuous suctioning of gastric contents can lead to loss of hydrogen ions (H+) and chloride ions (Cl-) from the stomach, resulting in metabolic alkalosis.

b. Metabolic acidosis: Metabolic acidosis is less likely in this scenario unless there are other factors contributing to acidosis, such as renal dysfunction or excessive administration of certain medications. Suctioning of gastric contents would lead to loss of acid, which could potentially predispose the client to metabolic alkalosis rather than metabolic acidosis.

c. Respiratory alkalosis: Respiratory alkalosis is less likely to occur in this scenario. Although the client is NPO and may be experiencing some respiratory compensation due to metabolic alkalosis, the primary acid-base disturbance would be metabolic rather than respiratory.

d. Respiratory acidosis: Respiratory acidosis is not typically associated with suctioning of gastric contents. Instead, it occurs due to inadequate alveolar ventilation, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. This imbalance is more commonly seen in conditions such as respiratory depression, neuromuscular disorders, or airway obstruction.

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The nurse is assessing a client with acute heart failure. Which finding would the nurse anticipate?

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Correct Answer is B

Explanation

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