PCC Unit 2 Gas Exchange

Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion

ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

ANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient's gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.

The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy

ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid

ANS: A Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreased blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy

ANS: A The patient is experiencing respiratory acidosis (∃pH and #PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system

ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange? a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60

ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.

Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease

ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications.

The student nurse is questioning the instructor about the different types of chemotherapeutic agents used to treat cancer. Which statement by the instructor best explains why lung cancers are less sensitive to antineoplastic agents than other types of cancers? A) "Lung cancer cells have a low growth fraction, so they are less sensitive to antineoplastic agents." B) "Lung cancer cells grow in a high-oxygen environment, so they are not very sensitive to antineoplastic agents." C) "Lung cancer cells have been growing for a long time before detection, so they are less sensitive to antineoplastic agents." D) "Lung cancer cells have a very erratic cell cycle, so they are not very sensitive to antineoplastic agents."

Answer: A Explanation: Growth fraction is a ratio of the number of replicating cells to the number of resting cells. Antineoplastic drugs are much more toxic to tissues and tumors with high growth fractions. Breast and lung cancers have low growth fractions. Lung cancer cells may grow for a long time before detection, but this is not the primary reason they are less susceptible to antineoplastic agents. A high-oxygen environment is not the reason why lung cancer cells are less sensitive to antineoplastic agents. Lung cancer cells do not have a very erratic cell cycle.

The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. What assessment information caused the nurse to come to this conclusion? A) Body mass index (BMI) 35.8 B) Former cigarette smoker C) Blood pressure 132/88 mmHg D) Age 45 years

Answer: A Explanation: Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the client's weight.

The nurse is planning care to address ineffective airway clearance for a client with lung cancer. Which interventions should the nurse include in the client's plan of care? Select all that apply. A) Increase fluid intake to 3000 mL per day. B) Turn, cough, and deep breathe every 2 hours. C) Chest percussion every 8 hours D) Smoking cessation education E) Administer pneumococcal vaccine.

Answer: A, B, C Explanation: An adequate fluid intake is needed. Clients with pneumonia should increase their fluid intake in order to decrease the viscosity of respiratory secretions. Turning, coughing, deep breathing and chest percussion can help clear secretions. Administering the pneumococcal vaccine and educating the client on smoking cessation are important in treating a client with pneumonia, but they would be aligned with a different nursing diagnosis.

A nurse is caring for a client recovering from a wedge resection of the left lung for a tumor. What would be appropriate goals for the nursing diagnosis of ineffective airway clearance? Select all that apply. A) Minimize accumulation of fluid. B) Participation in care by the client C) Maintain a patent airway. D) Maintain current weight. E) Express feelings and concerns.

Answer: A, C Explanation: All of the outcomes for this client are viable, but appropriate outcomes for the diagnosis of ineffective airway clearance are maintaining a patent airway and minimizing the accumulation of fluid.

Which client is at highest risk for a nonthrombotic pulmonary embolism? A) The pregnant client with gestational diabetes B) The client who postoperative from a femur fracture repair C) The client with a primary lung tumor D) The client who uses intravenous illicit drugs

Answer: B Explanation: Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs after fracture of long bone (typically the femur) releases bone marrow fat into the circulation. The other clients may be at risk for pulmonary embolism; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli.

The nurse has instructed a client recovering from a pulmonary embolism on long-term anticoagulant therapy. Which client statement indicates that instruction has been effective? A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor, and avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."

Answer: B Explanation: Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-Alert bracelet that identifies anticoagulant therapy. The client should avoid green salads because of the vitamin K content. The statements about bruising being normal and expecting bloody sputum mean the client is in need of additional instruction on anticoagulant therapy.

The nurse is providing discharge instructions to an older client who is going home after having a total knee replacement. What teaching will the nurse include to prevent the development of a thrombosis or pulmonary embolism? Select all that apply. A) Place pillows under the knees when in bed. B) Use compression stockings. C) Limit ambulation. D) Limit fluids. E) Continue with leg exercises.

Answer: B, E Explanation: A client being discharged after having orthopedic surgery is at increased risk for pulmonary embolism. The nurse should instruct the client to continue with leg exercises and use compression stockings to reduce the risk of deep vein thrombosis formation. The client should be encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless another physiological condition exists that would necessitate a fluid restriction.

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. The nurse would identify which diagnosis as a priority for this client? A) Ineffective Tissue Perfusion B) Anxiety C) Impaired Gas Exchange D) Impaired Physical Mobility

Answer: C Explanation: A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing impaired gas exchange. This would be the priority for the client at this time. The client may have ineffective tissue perfusion; however, this is not the priority. The client may be experiencing anxiety; however, this is not the priority at this time either. There is not enough information to determine whether the client is at risk for impaired mobility.

A male Hispanic client has had a lung biopsy. The results indicate a poor prognosis for the client. The family is at the client's bedside and begins to moan and cry loudly. The doctor has told the nurse that he needs to have the consent form signed for surgery. The client has asked the nurse to allow the family private time. What should the nurse do at this time? A) Ask the family to come back later. B) Have the doctor get the consent with the family present. C) Provide the client and family privacy. D) Take the client to another room.

Answer: C Explanation: As the client advocate, the nurse would allow this family to bond according to their customs. Asking the family to leave may cause extreme stress to the client and family. It would not be appropriate for the doctor to try to explain the surgery while the family is grieving. Taking the client to another room would deprive the client from participating in his family's customs.

The nurse is caring for a client who is undergoing diagnostic tests to rule out lung cancer. The client asks the nurse why a computed tomography (CT) scan was ordered. What is the best response by the nurse? A) "The doctor prefers this test." B) "To rule out the possibility that your problems are caused by pneumonia." C) "It is more specific in diagnosing your condition." D) "Why are you concerned about this test?"

Answer: C Explanation: Computed tomography (CT) is used to evaluate and localize tumors, particularly tumors in the lung parenchyma and pleura. It also is done before needle biopsy to localize the tumor. In addition, CT scanning can detect distant tumor metastasis and evaluate tumor response to treatment. A chest x-ray can be used to diagnose pneumonia. The client's question is valid and should not be minimized by asking why the client is having concerns about the test.

The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism. The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? A) It is considered second-line treatment. B) Major hemorrhage is common. C) Heparin and warfarin (Coumadin) are usually initiated at the same time. D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.

Answer: C Explanation: Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary embolism. While major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin, alters the synthesis of vitamin K-dependent clotting factors.

The nurse caring for a client recovering from an abdominal hysterectomy suspects the client is experiencing a pulmonary embolism. What did the nurse assess in this client? A) Nausea B) Decreased urine output C) Dyspnea and shortness of breath D) Activity intolerance

Answer: C Explanation: Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever. Decreased urine output, activity intolerance and nausea are not clinical manifestations of a pulmonary embolism.

The nurse is planning care for a client with a pulmonary embolism. Which intervention would assist with the client's decrease in cardiac output? A) Provide oxygen. B) Keep protamine sulfate at the bedside. C) Monitor pulmonary arterial pressures. D) Assess for bleeding.

Answer: C Explanation: The client with a pulmonary embolism and decreased cardiac output is at risk for developing right heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the client with ineffective protection. Oxygen would be appropriate for the client with impaired gas exchange.

The nurse is caring for a client in a community clinic who wishes to quit smoking. The client asks the nurse, "If I quit smoking, will my risk of lung cancer be the same as a nonsmoker?" Which is the best response by the nurse? A) "No one knows for sure what the risk is for someone who quits smoking." B) "Your risk of lung cancer will be equal to that of a non-smoker." C) "Your risk of lung cancer will decline if you quit, but it will remain higher than a non-smoker's." D) "Your risk of lung cancer will never drop because the damage has already been done."

Answer: C Explanation: While the client's risk for lung cancer will diminish sharply upon quitting smoking, it will not drop to the level of someone who never smoked. Another factor when calculating risk is the client's exposure to secondhand smoke, which also increases risk. Although damage has been done, the client's risk will drop dramatically upon quitting smoking. The risk for someone who quits is known to be dramatically less than for someone who continues to smoke.

The nurse is preparing to discharge a client recovering from a pulmonary embolism. How should the nurse instruct this client? Select all that apply. A) Limit the use of over-the-counter medications. B) Diet to include green leafy vegetables C) Symptoms of recurrence D) Anticoagulant administration schedule E) Resume normal activity level.

Answer: C, D Explanation: The client being discharged after treatment for a pulmonary embolism needs to be instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and the schedule for anticoagulation administration.

The nurse is caring for an 86-year-old client who is very thin and emaciated. The client reports new onset of shortness of breath. A chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung cancer. Due to the client's poor nutritional status, chemotherapy is not an option. The physician also believes that the location of the cancer would make radiation therapy unsuccessful. In advocating for this client, what should the nurse encourage the healthcare team to do? A) Provide palliative care to keep the client comfortable without diagnostic testing. B) Perform any procedure necessary to diagnose the client properly. C) Promote the use of blood tests to diagnose the suspected cancer. D) Determine the client's and family's wishes regarding diagnostic testing.

Answer: D Explanation: An elderly emaciated client may have few options for treatment of cancer, if confirmed. The best course of treatment may be palliative care, but it is the choice of the client and family that should direct the plan of care and choices of diagnostic testing.

A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. For the prevention of which postoperative complication are these instructions being provided? A) Infection B) Delayed wound healing C) Contractures D) Deep vein thrombosis

Answer: D Explanation: The best care for a pulmonary embolism is prevention. Since surgical clients have an increased risk of developing a pulmonary embolism postoperatively, instructions should include ways to encourage movement, such as leg exercises, and the need for pneumatic compression devices to maintain lower extremity circulation and prevent the development of a deep vein thrombosis. Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or prevent contractures.

A nurse caring for a client with a pulmonary embolism expects to find which diagnostic result? A) Patchy infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on EKG

Answer: D Explanation: With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The client with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO2) will be decreased, not increased, due to rapid breathing.