The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

Metabolic alkalosis

Metabolic acidosis

Respiratory alkalosis

Respiratory acidosis

Answer and Explanation

The Correct Answer is C

A. Metabolic alkalosis: This condition results from excess bicarbonate or loss of acids through vomiting or diuretics. It is not associated with rapid, shallow breathing, especially in the early phase of heart failure.
B. Metabolic acidosis: Typically seen in states of increased acid production or bicarbonate loss, such as in renal failure or diarrhea. It is not the expected initial response to hyperventilation caused by early heart failure.
C. Respiratory alkalosis: Rapid, shallow breathing (tachypnea) leads to excessive exhalation of CO₂, resulting in decreased carbonic acid and increased blood pH. This is the typical early blood gas finding in acute heart failure due to hypoxia-driven hyperventilation.
D. Respiratory acidosis: This occurs when CO₂ is retained due to hypoventilation. Since the client is hyperventilating rather than hypoventilating, respiratory acidosis would not be present initially.

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Correct Answer is ["A","B","E"]

Explanation

A. Learn about stress management education and join a support group: Education and peer support help clients understand anxiety and reduce isolation. These tools promote healthy coping strategies and improve long-term emotional resilience.
B. Re-establish priorities and strike a healthy balance between work and play: Balancing responsibilities with enjoyable activities reduces stress and prevents burnout. Prioritizing tasks allows clients to manage anxiety more effectively and feel more in control.
C. Avoid verbalizing or writing about feelings of anxiety: Avoidance can worsen anxiety over time. Verbalizing or journaling emotions allows clients to process and release anxious thoughts rather than suppressing them.
D. Delay stressful tasks as desired: Delaying tasks may provide short-term relief but can increase stress and anxiety later. Timely task completion supports a sense of accomplishment and reduces prolonged worry.
E. Engage in a daily exercise program: Regular physical activity helps regulate mood and lowers anxiety levels. Exercise reduces stress hormones and improves mental clarity, making it an effective coping strategy.

A. Shift of rib cage toward affected side B. Shift of trachea, esophagus, heart, and great vessels C. Fluctuation of the fluid in the water-seal chamber D. Sucking sound heard on inspiration and expiration

Correct Answer is B

Explanation

A. Shift of rib cage toward affected side: The rib cage does not typically shift in tension pneumothorax. Instead, the thorax on the affected side may appear hyperinflated or fixed in inspiration but does not physically shift toward the affected side.
B. Shift of trachea, esophagus, heart, and great vessels: A tension pneumothorax can cause increased intrathoracic pressure, pushing the mediastinal structures toward the unaffected side. This mediastinal shift is a critical sign and can lead to impaired cardiac output and respiratory collapse.
C. Fluctuation of the fluid in the water-seal chamber: This is an expected finding in a chest tube system and indicates proper function. It does not reflect a mediastinal shift and is not specific to tension pneumothorax.
D. Sucking sound heard on inspiration and expiration: This is more commonly associated with an open pneumothorax, not a tension pneumothorax. Tension pneumothorax involves air trapping without an external opening.

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The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","E"]

Explanation

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Correct Answer is B

Explanation

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