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

Explanation

A. Defibrillator: Ventricular arrhythmias, such as ventricular tachycardia or fibrillation, can be life-threatening and require immediate defibrillation if the client is pulseless or unstable. Having a defibrillator ready is the highest priority for emergency response.
B. Cardioversion equipment: Cardioversion is typically used for atrial arrhythmias or stable ventricular tachycardia. It is synchronized with the cardiac rhythm and not appropriate for pulseless ventricular fibrillation, which needs unsynchronized defibrillation.
C. An ECG machine: An ECG is important for diagnosing the specific arrhythmia but does not treat the condition. While useful for assessment, it is not the priority in an emergency involving unstable ventricular rhythms.
D. A suction machine: Suction may be needed later if the client loses consciousness or vomits, but it is not specific to the treatment of ventricular arrhythmias and is not the first piece of equipment to prepare.

A. "Chest pain should always be evaluated." B. "But you are okay now." C. "It must have been frightening for you." D. "We would not let you die."

Correct Answer is C

Explanation

A. "Chest pain should always be evaluated.": While true, this response shifts focus away from the client’s emotional experience. It is more clinical than empathetic, and may not validate the client's current distress.
B. "But you are okay now.": This can feel dismissive of the intense fear the client experienced. While intended to reassure, it overlooks the need for emotional validation during recovery from a panic attack.
C. "It must have been frightening for you.": This statement acknowledges and validates the client’s emotional experience. Empathic reflection helps reduce shame and fosters therapeutic rapport during an anxiety crisis.
D. "We would not let you die.": This response may sound comforting but unintentionally minimizes the client’s perceived fear and lacks therapeutic depth. It doesn’t address the emotional intensity of the situation.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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