Practice Quiz

ANCC Medical-Surgical Nursing Exam Prep

Category - Pulmonary

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The nurse is assessing Mr. Guzman, a 40-year-old baker with no significant past medical history, who was admitted to the Emergency Department. The assessment findings include a decrease in level of consciousness; rapid, shallow respirations; nasal flaring; sterna and intercostals retractions; and cyanosis around the lips and oral mucosa. The ABG reveals pH - 7.24, pCO2 - 55, and PaO2 - 50. Which statement best describes these findings?
  1. Acute respiratory distress with respiratory acidosis and hypoxemia
  2. Mild respiratory distress with acidosis and hypoxemia
  3. Acute respiratory distress with respiratory alkalosis and hypoxemia
  4. No distress; ABG is normal
Explanation
Answer - A - The analysis of the blood gas information, in conjunction with the clinical manifestations, indicates acute respiratory distress with respiratory acidosis and hypoxemia. The client’s blood gas pH is low and represents acidosis. The pCO2 is elevated (normal pCO2 is 35-45 mmHg) and demonstrates hypercapnia. A normal PaO2 is in the range of 75 to 100 mmHg, so this client’s PaO2 is considered low.
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