BSN 246 HESI V3 HEALTH ASSESSMENT
PRACTICE QUESTIONS AND ANSWERS
RATED A+ | NIGHTINGALE | 2024/2025
GUIDE
The nurse is caring for a client with diabetic ketoacidosis and documents
that the client is experiencing Kussmaul's respirations. Which patterns
did the nurse observe? Select all that apply.
1. Respirations that are shallow
2. Respirations that are increased in rate
3. Respirations that are abnormally slow
4. Respirations that are abnormally deep
5. Respirations that cease for several seconds - Correct Answer - 2.
Respirations that are increased in rate
4. Respirations that are abnormally deep
Kussmaul's respirations are abnormally deep and increased in rate.
These occur as a result of the compensatory action by the lungs. In
bradypnea, respirations are regular but abnormally slow. Apnea is
described as respirations that cease for several seconds.
,A client who is found unresponsive has arterial blood gases drawn and
the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm
Hg), and is 22 mEq/L (22 mmol/L). The nurse interprets the results as
indicating which condition?
1. Metabolic acidosis with compensation
2. Respiratory acidosis with compensation
3. Metabolic acidosis without compensation
4. Respiratory acidosis without compensation - Correct Answer - 4.
Respiratory acidosis without compensation
The acid-base disturbance is respiratory acidosis without compensation.
The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35
to 45 mm Hg). In respiratory acidosis the pH is decreased and the Pco2
is elevated. The normal bicarbonate ) level is 21 to 28 mEq/L (21 to 28
mmol/L). Because the bicarbonate is still within normal limits, the
kidneys have not had time to adjust for this acid-base disturbance. In
addition, the pH is not within normal limits. Therefore, the condition is
without compensation. The remaining options are incorrect
interpretations.
The nurse notes that a client's arterial blood gas (ABG) results reveal a
pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors
the client for which clinical manifestations associated with these ABG
results? Select all that apply.
1. Nausea
, 2. Confusion
3. Bradypnea
4. Tachycardia
5. Hyperkalemia
6. Lightheadedness - Correct Answer - 1. Nausea
2. Confusion
4. Tachycardia
6. Lightheadedness
Respiratory alkalosis is defined as a deficit of carbonic acid or a
decrease in hydrogen ion concentration that results from the
accumulation of base or from a loss of acid without a comparable loss of
base in the body fluids. This occurs in conditions that cause
overstimulation of the respiratory system. Clinical manifestations of
respiratory alkalosis include lethargy, lightheadedness, confusion,
tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting,
epigastric pain, and numbness and tingling of the extremities.
Hyperventilation (tachypnea) occurs. Bradypnea describes respirations
that are regular but abnormally slow. Hyperkalemia is associated with
acidosis.
The nurse reviews the blood gas results of a client with atelectasis. The
nurse analyzes the results and determines that the client is experiencing
respiratory acidosis. Which result validates the nurse's findings?
1. pH 7.25, Paco2 50 mm Hg (50 mm Hg)
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