Mod 2: Ch 12, 31, 32

The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The international normalized ratio (INR) is 6.9. Which one of these questions is most appropriate for the nurse to ask at this time? "Have you eaten a lot of green leafy vegetables?" "Have you experienced swelling of your legs?" "Were you massaging your calves?" "Have you taken any aspirin or salicylates?"

"Have you taken any aspirin or salicylates?" It is most appropriate for the nurse to ask about the use of aspirin and salicylates. Use of aspirin and salicylates will prolong the INR and cause gastric irritation and bleeding.Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR; bleeding would be unlikely. Unilateral swelling rather than bilateral swelling is typically present in DVT, which may lead to PE, but is not present in this situation. Massaging the calves may present a risk for PE if deep vein thrombosis is present, but does not relate to GI bleeding and prolonged INR.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about prevention of complications? A. "I am here to receive the yearly pneumonia shot again." B. "I am here to get my yearly flu shot again." C. "I should avoid large gatherings during cold and flu season." D. "I should cough into my upper sleeve instead of my hand."

"I am here to receive the yearly pneumonia shot again." The statement by the client, "I am here to receive the yearly pneumonia shot again" indicates a need for further teaching. The CDC recommends that adults older than 65 years be vaccinated with two vaccines, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax would have Prevnar 13 about a year or more later, but not annually. Older clients are encouraged to receive a flu shot annually because the vaccine is formulated annually, depending on anticipated strains for the upcoming year. It is a good idea to avoid large gatherings during cold and flu season. Recommendations from the Centers for Disease Control and Prevention for controlling the spread of flu include coughing or sneezing into the upper sleeve rather than into the hand.

The nurse is providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will communicate? "Sedation is needed so your loved one does not rip the breathing tube out." "Suctioning is important to remove organisms from the lower airway." "Paralytics and sedatives help decrease the demand for oxygen." "We are encouraging oral and IV fluids to keep your loved one hydrated."

"Paralytics and sedatives help decrease the demand for oxygen." The nurse will tell the family that paralytics and sedation are administered to decrease oxygen demand and promote compliance with mechanical ventilation.Sedation is needed more for its effects on oxygenation than to prevent the client from ripping out the endotracheal tube. Suctioning is performed to remove upper airway secretions and maintain airway patency. Clients receiving mechanical ventilation typically receive hydration by enteral tube or parenteral route and not orally.

The clinic nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? "Handwashing is the best way to prevent transmission." "I should avoid kissing and shaking hands." "It is best to cough and sneeze into my upper sleeve." "The intranasal vaccine can be given to everybody in the family."

"The intranasal vaccine can be given to everybody in the family." Further teaching is needed when the client states that the intranasal vaccine can be given to everybody in the family. The intranasal flu vaccine is approved for adult clients up to age 49 who are not pregnant. Washing hands frequently is the best way to prevent the spread of illnesses such as the flu. Avoiding kissing and shaking hands are two ways to prevent transmission of the flu. A recommendation from the Centers for Disease Control and Prevention for controlling the spread of the flu is to sneeze or cough into the upper sleeve rather than into the hand

The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? "The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." "Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued." "If bleeding develops, we will give platelets to reverse the anticoagulant."

"Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." The nursing student correctly understands safety and effectiveness of Coumadin therapy when the student states that the international normalized ratio or INR reflects a therapeutic level when between 2 and 3. The INR is the diagnostic test used to measure effectiveness of anticoagulation with warfarin. Subtherapeutic levels below 2 pose a risk for clots to develop; values above 3 pose a risk for bleeding.Enoxaparin (Lovenox) is a low-molecular-weight heparin that is given by the subcutaneous, not intramuscular route. Heparin and warfarin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? "You will not spread the disease unless you stop taking your medication." "You will not pose an increased risk of disease to the people you have been living with." "You will have to take these medications for at least 1 year." "Your sputum may turn a rust color as your condition gets better."

"You will not pose an increased risk of disease to the people you have been living with." The nurse tells the client that he/she will not be contagious to the people he/she lives with. The people the client has been living with have already been exposed and need to be tested. They cannot become at higher risk simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. However, the risk for transmission is reduced after the infectious person has received proper drug therapy for 2 to 3 weeks, clinical improvement occurs, and acid-fast bacilli (AFB) in the sputum are reduced. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. The following prescriptions have been given for the client. In what sequence will the nurse perform these actions? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze post-intubation arterial blood gases (ABGs). 2, 1, 3, 4 4, 3, 1, 2 3, 4, 2, 1 4, 2, 1, 3

4, 2, 1, 3 ABGs which evaluate oxygenation, ventilation, and pH would be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures would then be obtained before anti-infective medications are administered. Then levofloxacin can be given. Client and family education on communication methods is important, but is the lowest priority.

When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse? A client who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing A client receiving mechanical ventilation who has tracheal deviation A client who was recently extubated and is reporting a sore throat A client who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min

A client receiving mechanical ventilation who has tracheal deviation The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock.The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.

The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)? A client with diabetes and cellulitis of the leg A client receiving IV fluids through a peripheral line A client returning from an open reduction and internal fixation of the tibia A client with fluid volume deficit and hypokalemia receiving potassium supplements

A client returning from an open reduction and internal fixation of the tibia To reduce the risk for developing PE, the nurse provides immediate interventions for the client returning from an open reduction and internal fixation of the tibia. Surgery and perioperative immobility are very high risks for deep vein thrombosis and PE. Orthopedic surgery compounds this risk.No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE. Cellulitis is treated with antibiotics. Diabetic vascular disease is typically arterial in nature, rather than venous. The client receiving IV fluids through a peripheral line who evidences no problem with the IV or with breakage of the catheter appears to require no immediate nursing intervention. While severe fluid volume deficit and resulting hemoconcentration may pose a risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery, and for the client with hypokalemia, no evidence reveals risk for PE.

The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism (PE)? A woman who frequently flies to Europe A man who works on a farm A man admitted for a myocardial infarction A woman with a bleeding disorder

A woman who frequently flies to Europe Individuals who engage in prolonged and frequent air travel are at higher risk for PE due to the dependent position of the legs during long air flights.A 67-year-old man who works on a farm poses a low risk due to his active lifestyle. A myocardial infarction is caused by a thrombus or occlusion of the coronary arteries, not of the leg veins. If the MI client is on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.

1. A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? a. An obese client with leg trauma b. A pregnant client with acute asthma c. A client with diabetes who has cholecystitis d. A client with pneumonia who is immunocompromised.

A. An obese client with leg trauma An obese client with leg trauma has two risk factors for development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for development of pulmonary embolism

1. A nurse is caring for several clients in the ICU. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome? a. Aspirating gastric contents b. Getting an opioid overdose c. Experiencing an anaphylactic reaction d. Receiving multiple blood transfusions

A. Aspirating gastric contents Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes, which release inflammatory mediators; the process progresses to pulmonary edema, vascular narrowing and obstruction, pulmonary hypertension, and impaired gas exchange. Getting an opioid overdose is not as common as a cause of ARDS as is aspiration pneumonia; this more likely will cause depressed respirations. Although anaphylaxis may cause ARDS, it is not a common cause. Although multiple blood transfusions have been known to precipitate ARDS, they are not an common cause

1. A client with chest trauma is admitted to the emergency department. Which intervention takes priority? a. Ensure patent airway. b. Monitor the cardiac rhythm. c. Release dressing in the tension pneumothorax. d. Anticipate intubation for respiratory distress.

A. Ensure patent airway. Ensuring the client has a patent airway supports the primary intervention of prioritizing care for a client with chest trauma. The nurse should ensure that the client is getting sufficient air for respirations. Monitoring the cardiac rhythm is done after obtaining a patent airway. This follows the ABC's of emergency management. Release of dressing in tension pneumothorax is usually done to monitor the wound after a sucking chest wound is covered

1. A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do? a. Hyperoxygenate with 100% oxygen before and after suctioning b. Suction two or three times in quick succession to remove secretions c. Use the technique of short, pushing movements when applying suction d. Apply suction for no more than 10 seconds while inserting the catheter

A. Hyperoxygenate with 100% oxygen before and after suctioning Suctioning removes not only secretions but also oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after. Suction should be performed only as needed to maintain a patent airway; excessive suctioning irritates the mucosa, which increases secretion production. Short pushing movements can cause tracheal damage. To prevent trauma to the trachea, suction should be applied only while removing the catheter, not while inserting

1. A client reports fever, headache, extreme tiredness, dry cough, sore throat, runny nose, muscle aches, nausea, vomiting, and diarrhea. Which organism is responsible for this condition? a. Influenza virus b. Toxoplasma gondii c. Human herpes virus-8 d. Cryptosporidium muris

A. Influenza virus Fever, headache, extreme tiredness, dry cough, sore throat, runny nose, muscle aches, nausea, vomiting, and diarrhea are symptoms of influenza. Influenza is cause the Influenza virus. Toxoplasma gondii causes fever, altered mental status, headache, and seizures. Human herpes virus-8 causes vascular lesions on the skin. Cryptosporidium muris causes watery diarrhea and weight loss.

1. The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema? a. Palpate around the tube insertion sites for crepitus b. Auscultate the breath sounds for crackles and atelectasis c. Observe the client for the presence of barrel-shaped chest d. Compare the length of inspiration with the length of expiration

A. Palpate around the tube insertion sites for crepitus Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated. Crackles and atelectasis are unrelated to crepitus. They occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of inspiration with the length of expiration is unrelated to subcutaneous emphysema, which involves gas in the soft tissues from a pleural leak.

1. After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? a. Pink b. Clear c. Green d. Yellow

A. Pink With a pulmonary embolus, there is partial or complete occlusion of pulmonary flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection

1. A client who is prescribed diuretic therapy develops metabolic alkalosis. To which intervention should the nurse give priority as the healthcare team corrects the alkalosis? a. Preventing falls b. Monitoring electrolytes c. Administering antiemetics d. Adjusting the diuretic therapy

A. Preventing falls Preventing falls is the priority nursing intervention as the healthcare team corrects the alkalosis. A client with alkalosis has hypotension and muscle weakness, which increases the risk for injury due to falls. Monitoring electrolytes and adjusting diuretic therapy requires prescriptive authority and are important actions primarily managed by the healthcare provider. Antiemetics are prescribed by the healthcare provider when there is nausea and vomiting. Although nurses have an important role in assisting the healthcare team with implementing prescriptions, preventing falls is the priority within the nursing scope of practice and does not require a prescription

The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure? Select all that apply. A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a C5 spinal cord injury D. Client using client-controlled analgesia E. Client experiencing cocaine intoxication

ANSWER IS A, B, C Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and intercostal muscles are affected. Opiates used in client controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure.Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

The nurse is providing education for a client who is taking isoniazid, rifampin, and ethambutol for tuberculosis. Which of these points does the nurse include in the plan of care? Select all that apply. A. Take a supplement containing B vitamins. B. Avoid alcohol containing beverages. C. Have kidney function tests monthly. D. Report changes in vision to the health care provider. E. Notify the health care provider for red-orange urine.

ANSWER IS A, B, D Teach the client to take a daily multiple vitamin that contains the B-complex vitamins while on this drug as deficiency may occur. These medications can cause liver damage, which is potentiated by alcohol. Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Contact lenses will also be stained and oral contraceptives will be less effective. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless and expected. Both isoniazid and pyrazinamide may cause liver failure. Side effects of major concern include jaundice, bleeding, and abdominal pain

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess? Select all that apply. A. Dizziness and syncope B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum F. Tachycardia

ANSWER IS A, C, F Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over two weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.

A nursing is caring for a client who suddenly developed acute respiratory distress after returning home from an extended business trip in a foreign country. What actions by the nurse are most appropriate before the cause of the problem is identified? (Select all that apply.) a. Ask the client where the travel specifically occurred and whether he or she was exposed to anyone who was ill. b. Use Contact Precautions with this client and use gloves and gown for care. c. Prepare to administer isoniazide (INH) as soon as the first dose is available. d. Monitor the results of the client's blood urea nitrogen (BUN, creatinine, and liver function studies. e. Collaborate with the interprofessional team to obtain arterial blood gases and prepare to intubate the client. f. Assist with obtaining sputum cultures for acid-fast bacilli to send to the laboratory for analysis.

ANSWER IS A, D, E A is correct. This client has recently traveled and perhaps been exposed to MERS. It is critical to determine the geographic area(s) the client has been in. B is not completely correct. Although Contact Precautions should be used, Airborne Precautions must also be instituted. C is not correct. Isoniazide is used only for tuberculosis. The sudden and rapid onset of this client's respiratory distress is not consistent with tuberculosis. D is correct because MERS can rapidly be complicated with sepsis and multi-organ dysfunction syndrome. E is correct because any client with acute respiratory distress can have progression to complete respiratory failure. Arterial blood gas results help determine the adequacy of gas exchange and the need for oxygen therapy and/or mechanical ventilation. F is incorrect. This test is only for tuberculosis. The sudden and rapid onset of this client's respiratory distress is not consistent with tuberculosis.

Which laboratory values are most important for a nurse to monitor for a client who is receiving a heparin infusion for treatment of a pulmonary embolism when warfarin is added to the drug therapy? (Select all that apply.) a. Activated partial thromboplastin time b. Albumin levels c. Factor V levels d. Hepatic function tests e. International normalized ratio f. Platelet count g. Serum osmolarity

ANSWER IS A, E, F Heparin dosing is monitored and adjusted with activated partial thromboplastin times (aPTT) and platelet counts. Warfarin dosing is monitored and adjusted based on the international normalized ratio (INR). Although warfarin is protein-bound and hypoalbuminemia may affect dosing, it is not routinely monitored at the initiation of warfarin therapy. Hepatic function and Factor V assessment are not part of dose monitoring for either heparin or warfarin.

What information is most important for a nurse to include when teaching a client with tuberculosis about the prescribed first-line drug therapy? a. "Report darkening or reddening of the urine while taking Rifampin." b. "Do not drink alcohol in any quantity while taking Isoniazid." c. "Restrict fluid intake to 2 quarts of liquid a day on pyrazinamide." d. "Temporary visual changes while taking ethambutol are not serious."

ANSWER IS B All the drugs for tuberculosis are liver toxic and can cause liver damage. Drinking alcohol compounds this damage and should be ingested only in small quantities, if at all. The reddened urine is an expected side effect of Rifampin therapy and, while the patient should be taught about this side effect, it does not need to be reported. Fluids should be increased, not decreased for a patient taking pyrazinamide to prevent gout or hyperuricemia. The visual changes associated with ethambutol are serious and not temporary. If the drug is not stopped when changes occur, it can cause optic neuritis and lead to blindness.

When reviewing the laboratory values for a client admitted with pneumonia, which result would cause the nurse to collaborate quickly with the health care provider? a. White blood cell (WBC) count of 14,526 mm3 b. PaO2 68 mm Hg c. PaCO2 46 mm Hg d. Blood glucose 146 mg/dL

ANSWER IS B Although all values are abnormal (PaCO2 is only slightly elevated), they are expected findings in clients with pneumonia or any other severe infection. The very low PaO2 level indicates severe hypoxemia and great risk for death without immediate intervention.

The community health nurse is collaborating with the local health department on containment of an anticipated pandemic influenza outbreak. The nurse advises the health department that the best method to prevent outbreaks of pandemic influenza is which of these? A. Avoiding public gatherings at all times B. Early recognition and quarantine of affected persons C. Vaccinating community members with pneumonia vaccine D. Widespread distribution of antiviral drugs

ANSWER IS B Early recognition and quarantine of affected persons is the best way to prevent outbreaks of pandemic influenza. The recommended approach to disease prevention consists of quick recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. Public gatherings need to be avoided only in the case of widespread outbreak of influenza in the community. A vaccine (Vepacel) is available in case of H5N1 outbreaks, but is stockpiled and not part of general influenza vaccination. The pneumonia vaccine is recommended for high-risk populations because pneumonia may be a complication of influenza. The current influenza vaccine is updated, re-evaluated, and changed yearly to meet anticipated changes in the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

A client asks why the provider has recommended that he breathe into a paper bag for several minutes when his anxiety disorder causes him to hyperventilate. What is the nurse's best response? a. "Even your exhaled breath still has some oxygen in it and rebreathing this air ensures that you won't pass out from lack of oxygen." b. "When you breathe fast you can lose too much carbon dioxide and rebreathing this air keeps you from becoming dizzy and falling." c. "Rapid breathing can lead to dehydration from excessive fluid loss and rebreathing this air helps you retain fluid in the form of vapor moisture." d. "Breathing into the bag for several minutes helps you become distracted from whatever is making you anxious and allows you to calm down."

ANSWER IS B Rapid respirations allow carbon dioxide to be "blown off" and lead to respiratory alkalosis. Rebreathing air from the bag, which contains carbon dioxide, helps prevent the loss of carbon dioxide and alkalosis. The technique has nothing to do with oxygen or moisture retention. Breathing into a bag is highly unlikely to reduce anxiety, which is not its purpose.

The nurse is caring for a client who has developed postoperative respiratory acidosis. Which of these interventions will the nurse use to help correct this problem? A. Medicate for pain B. Encourage use of incentive spirometer C. Perform fingerstick blood glucose D. Encourage protein intake

ANSWER IS B The intervention that will best help the client with postoperative respiratory acidosis is to encourage the client to use the incentive spirometer. Respiratory acidosis is caused by hypoventilation. Improving ventilation through lung expansion, suctioning, or upright positioning will help to resolve this. While pain medication may make use of the incentive spirometer easier, narcotic analgesics may suppress respirations and worsen acidosis. There is no indication the client has an unstable blood glucose level. Protein intake facilitates wound healing, not resolution of acidosis.

When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A. Administering antibiotic prophylaxis B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client E. Placing a nasogastric tube F. Placing the client in a negative-airflow room

ANSWER IS B, C, D Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a client are all part of a VAP prevention bundle.Antibiotics are not given prophylactically, but are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle; if the stomach is distended, decompression with a NG tube after intubation may be used. If a client is going to receive mechanical ventilation for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing the client in a negative-airflow room may be used in a surgical suite or for care of clients with TB, but is not part of the VAP bundle. The client does not require this room.

The nurse in the community health clinic is planning education related to tuberculosis (TB). Which of these groups will the nurse target? Select all that apply. A. Breast cancer survivors B. Those in the local prison C. Homeless adults D. Recent immigrants to the United States E. Those who have received bacille Calmette-Guérin (BCG) vaccine

ANSWER IS B, C, D The groups the nurse plans to educate include those adults who live in crowded areas such as prisons and homeless shelters, and those who are recent immigrants to the USA. Other groups at higher risk for tuberculosis include those who abuse injection drugs or alcohol and those groups of lower socioeconomic status. Breast cancer survivors who are no longer undergoing immunocomprising therapy have the same risk as the general population. Receiving BCG, an immunization often given to individuals from overseas, is designed to prevent rather than cause TB. Clients who have received BCG vaccine within the last 10 years will have a positive skin test that can complicate interpretation.

The nurse coming on shift prepares to perform an initial assessment of a client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? Select all that apply. A. Ask visitors to leave the room. B. Assess the client's color and respirations. C. Confirm alarms and ventilator settings. D. Ensure that the tube is in proper position. E. Auscultate for bilateral breath sounds. F. Provide routine tracheostomy and mouth care.

ANSWER IS B, C, D, E Initial priorities when assessing the critically ill client are to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Markings on the endotracheal tube should be compared to previous records to ensure the tube remains in appropriate position. Auscultating for equal bilateral breath sounds assists in confirming that the tube is in the proper position above the carina.It is not necessary to ask visitors to leave. Having visitors remain with the client may promote comfort and prevent confusion.Routine tracheostomy care, an intervention, is performed according to schedule and as needed, and is not necessarily part of an initial assessment.

The nurse is caring for a client with acute respiratory failure and PaCO2 level of 88 mm Hg For which of these signs and symptoms will the nurse assess? Select all that apply. A. Hyperactivity B. Headache C. Shallow breathing D. pH 7.49 E. Fatigue

ANSWER IS B, C, E

Which blood laboratory values does the nurse need to evaluate to determine whether the client's acidosis has a respiratory origin or a metabolic origin? (Select all that apply.) a. Calcium b. HCO3− c. Lactic acid (lactate) d. PaCO2 e. PaO2 f. pH g. Potassium

ANSWER IS B, D, E In acidosis, the pH is low, and the potassium and lactic acid levels are elevated regardless of the origin or cause of the acidosis, making C, F, and G incorrect. The calcium level is not affected by acidosis, making response A incorrect. In metabolic acidosis, the PaO2 and the PaCO2 remain normal (or the PaCO2 slightly low) and the HCO3− is usually low as a cause of metabolic acidosis. In respiratory acidosis the PaO2 is low and the PaCO2 is high because the problem causing the acidosis is poor gas exchange with carbon dioxide retention. The HCO3− level is normal in acute respiratory acidosis and high in chronic respiratory acidosis.

When caring for a client who has the following blood gas results, which of these interventions does the nurse plan to use to correct the acid base disturbance? pH 7.47—pCO2 37 mm hg- HCO3 30 mEq/L (30 mmol/L)—pO2 88mm hg A. Endotracheal suctioning B. Applying oxygen C. Administering an antiemetic D. Administering sodium bicarbonate

ANSWER IS C This blood gas demonstrates metabolic alkalosis typically caused by vomiting or NG suction. The client loses potassium and retains bicarbonate; an antiemetic will reduce vomiting and correct the imbalance. Endotracheal suction is indicated for retained respiratory secretions, which would be reflected as a respiratory acidosis. The pO2 is between 80 and 100 mmHg, which is normal, supplementary oxygen is not required. Sodium bicarbonate is used to treat metabolic acidosis in certain situations.

A local hunter is admitted to the intensive care unit with a diagnosis of fulminant stage inhalation anthrax. Which assessment findings does the nurse anticipate is present? Select all that apply. A. Sore throat B. Rhinorrhea C. Harsh cough D. Stridor E. Low grade fever

ANSWER IS C, D The ICU nurse expects to find this client exhibiting a harsh cough and stridor. Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). The fulminant phase of inhalation anthrax begins after the client feels a little better and includes high fever, sudden onset of severe illness, including respiratory distress, hematemesis (bloody vomit), dyspnea, diaphoresis, stridor, chest pain, and cyanosis. When infection occurs through the lungs, the disease is nearly 100% fatal without treatment (CDC, 2015b). Inhalation anthrax has two stages: prodromal (or incubation period) and fulminant (with active disease). Symptoms take up to 8 weeks to develop after exposure (Chart 31-4).The prodromal stage occurs early in the course of illness and includes low-grade fever, fatigue, mild chest pain, and a dry, harsh cough. It is not accompanied by upper respiratory symptoms of sore throat or rhinitis.

The client from Clinical Judgement Challenge 32-2 (p. xxx) continues to deteriorate clinically and is to be intubated. What are the most important actions for the nurse to implement? (Select all that apply.) a. Obtain a cervical X-ray. b. Discontinue the IV fluids. c. Immediately page anesthesia or the Rapid Response Team (depending on institution policy). d. Confirm that suction is at the bedside and functioning properly. e. Have the crash cart available. f. Place client on nasal cannula oxygen. g. Have manual resuscitation bag with face mask at bedside. h. Verify bilateral breath sounds post-intubation.

ANSWER IS C, D, E, G, H Arrange for intubation per institution protocols. Suction, resuscitation bag with mask, and crash cart should be readily available for procedure (in an ICU, the crash cart may be optional). Post-intubation the nurse should confirm the presence of bilateral breath sounds. A cervical X-ray is not indicated, but a CXR is needed to confirm ET placement. The IV fluids should not be discontinued for intubation. They are required to administer medications and for fluid boluses if the patient becomes hypotensive. The rate may be decreased or they may be discontinued after the procedure if there is a concern for edema.

The nurse is trouble-shooting multiple ventilator alarms sounding for a client who is intubated and being mechanically ventilated. The alarms persist despite suctioning, repositioning the client, and ensuring the ventilator tubing is unobstructed. Which actions will the nurse perform next? (Select all that apply.) a. Turn off all ventilator alarms until a cause is found to prevent scaring the client. b. Page the healthcare provider to request additional sedation. c. Ensure the endotracheal tube marking is at the client's incisor. d. Increase the PEEP to improve oxygenation. e. Disconnect the client from the ventilator and use the manual resuscitation bag. f. Change all ventilator tubing. g. Start paging the respiratory therapist. h. Determine when the client received the last dose of the paralytic agent.

ANSWER IS C, E, G Multiple alarms sounding indicate a serious problem with ventilating the client and the client is in danger of hypoventilation and death. When multiple alarms are sounding and the problem cannot be identified and corrected quickly, the priority is to assess whether the problem is with the client or with the ventilator. Ensuring gas exchange is critical. Care for the client first and the ventilator last. Paging the respiratory therapist immediately is critical because this interprofessional team member is the ventilator expert. Turning off the alarms is not consistent with National Patient Safety Goals or safe care. Additional sedation does not solve the problems with the ventilator or the client's gas exchange. Checking the timing of the paralytic dose wastes valuable time and does not improve the client's ventilation or gas exchange. Changing the tubing might be helpful eventually but does not help the client right now. It is possible that the endotracheal tube has advanced to the point that it is no longer reaching the client's trachea, and its position should be checked quickly and immediately. To ensure adequate gas exchange, disconnect the client from this ventilator and provide ventilation with the manual resuscitation bag until someone else fixes or changes the ventilator. Manual resuscitation allows assessment of the client and determining lung compliance by the amount of effort needed to compress the bag, observing for chest rise with compressions, and determining whether this action results in improvement in the client's oxygen saturation. If manual ventilation improves the client's saturation, the issue is with the ventilator. If the client's saturation does not improve, the issue is with the client, which would require immediate intervention by the healthcare provider or Rapid Response Team.

The home care nurse is caring for an elderly client with streptococcal pneumonia. Which of these findings indicate a positive outcome to treatment? Select all that apply. A. The client states she will complete the entire dose of antibiotic prescribed. B. The client reports fatigue and malaise. C. White blood cell count is 16, 000 cells/cubic mm (16 × 109/L). D. The client has been afebrile for 48 hours.

ANSWER IS D A positive outcome been afebrile for 48 hours. Expected outcomes to treatment include negative blood and sputum cultures, normal WBC count and differential, and absence of fever. Fatigue may persist for several weeks. The normal WBC count is 5000-10,000 mm3 (5-10 × 109/L). A WBC count of 16,000 mm3 (16 × 109/L) indicates infection. The client stating compliance with treatment is positive, but is not an objective measurement of eradicating the infecting organism.

The nurse is caring for a client with long standing emphysema and respiratory acidosis. For which of these compensatory mechanisms will the nurse assess? A. Decrease rate of breathing B. Increased loss of bicarbonate through the kidneys C. Decreased depth of breathing D. Decreased loss of bicarbonate through the kidney

ANSWER IS D The compensatory mechanism the nurse anticipates is present in the client with long standing emphysema and respiratory acidosis is conservation of bicarbonate. A partially compensated respiratory acidosis will typically result. Increased loss of bicarbonate through the kidney, decreased rate, and depth of breathing will promote acidosis

A client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? A. Combination medication therapy is effective in eliminating cough and fever. B. Combination medication therapy improves adherence. C. Combination medication therapy has fewer side effects, particularly liver damage. D. The use of multiple medications destroys organisms quickly and reduces the development of drug-resistant organisms.

ANSWER IS D The nurse tells the client that multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Combination drug therapy is the most effective method for treating TB and preventing transmission. As the disease responds to treatment, the symptoms will decrease, but they are not eliminated. Combination drug therapy does not improve adherence to drug therapy. Isoniazid, rifampin, and pyrazinamide may cause liver damage.

A nurse is providing community education on seasonal influenza. What information will the nurse include in this presentation? (Select all that apply.) a. Adults older than 65 years should get the Prevnar-13 vaccination yearly. b. All adults older than 49 years should receive a Fluzone immunization annually. c. Sneeze into a disposable tissue or into your sleeve instead of your hand. d. Avoid large crowds during spring and summer to limit the change for getting the flu. e. Wash your hands frequently and after blowing your nose, coughing, or sneezing. f. Call your provider for an antiviral prescription within 3 days of getting symptoms.

Answer is B, C, E A is incorrect because Prevnar-13 is a pneumonia vaccine (not for influenza) and is only given once. B is correct because this is the injectable form of the influenza vaccine that is recommended for adults 49 and older to receive as an immunization yearly. C is correct because this technique is the one recommended by the CDC to limit infection spread. D is incorrect because influenza season in North America is in the fall and winter. E is correct because this action can limit infection spread. F is incorrect because these drugs are effective only if taken within 24 to 48 hours after symptoms begin.

1. A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply a. Headache b. Irritability c. Restlessness d. Hypertension e. Lightheadedness

Answer: A, B, C (headache, irritability, restlessness) .... Think acidosis! Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis. Irritability is a sign of cerebral hypoxia associated with early respiratory acidosis. Restlessness is a sign of cerebral hypoxia associated with early respiratory acidosis. Hypotension, not hypertension is a key feature of acidosis. Lightheadedness is a symptom of respiratory alkalosis, not acidosis

1. The nurse should refer a client to the pulmonary clinic for suspected TB based on which clinical indicators reported during the initial client interview? Select all that apply a. Vomiting b. Weight gain c. Hemoptysis d. Night sweats e. Bilateral crackles

Answer: C,D (Hemoptysis, night sweats) Erosion of lung tissue causes blood in the sputum, a classic sign of tuberculosis. Increased body temperature causes profuse diaphoresis, a classic sign of TB. Vomiting is associated with a GI obstruction or cancer. Weight loss, not weight gain is a sign of TB. Bilateral crackles are associated with excess fluid volume

1. What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. a. Crackles b. Atelectasis c. Hypoxemia d. Severe dyspnea e. Increased pulmonary wedge pressure

Answer: a, b, c, d Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin

The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L (26 mmol/L), PaO2 62 mm Hg Have the client breathe rapidly and deeply Apply oxygen Administer sodium bicarbonate Collaborate with the provider to increase the pH

Apply oxygen The priority action taken by the nurse is to administer oxygen. Hypoxemia is present, demonstrated by PaO2 below 75 mmHg. This is consistent with PE and supplementary oxygen is needed to improve tissue perfusion.Hyperventilation triggered by hypoxemia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). Breathing more rapidly and deeply will continue to "blow off" CO2 and cause further alkalosis. The bicarbonate level (HCO3-) (26 mEq/L) (26 mmol/L) is normal and requires no intervention. The pH level is already high.

The community health nurse is planning treatment for multi-drug resistant tuberculosis for a client who is addicted to heroin. Which action will be most effective in ensuring that the client completes treatment? Arrange for a health care worker to observe the client take the medication. Give the client written instructions about how to take prescribed medications. Have the client repeat medication names and side effects. Instruct the client about the possible consequences of nonadherence.

Arrange for a health care worker to observe the client take the medication. The most effective action for the nurse to take to ensure that the client completes the treatment is to arrange for the client to be directly observed during therapy. The client is unlikely to adhere to long-term treatment unless closely supervised while taking medications. Giving a client who is homeless and addicted to heroin written instructions on how to take prescribed medications is placing too much responsibility on the client to follow through. The fact that the client can state the names and side effects of medications does not mean that the client understands what the medications are and why he or she needs to take them. A client who is homeless and addicted to opiates would most likely be more concerned with obtaining drugs and shelter than with properly taking his or her medication.

A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next? Increase the sedation. Assess for adequate oxygenation. Explain that the tube in the client's throat helps with breathing. Request that the family leave to decrease the client's agitation.

Assess for adequate oxygenation. The next action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the chances of "ICU psychosis" and anxiety.

1. A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? a. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. b. Asses the need for suctioning when the high-pressure alarm of the ventilator is activated. c. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. d. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.

B. Asses the need for suctioning when the high-pressure alarm of the ventilator is activated. The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. Cuff should be inflated; it does not need to be tested this often. Humidification should occur, but the temperature should not be routinely changed. Regulating the PEEP according to the rate and depth of the client's respirations is a dependent function of the nurse and cannot be implemented without a healthcare provider's prescription

1. When caring for a client with pneumonia, which nursing intervention is the highest priority? a. Increase fluid intake. b. Employ breathing exercises and controlled coughing. c. Ambulate as much as possible. d. Maintain a NPO status

B. Employ breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated

1. The nurse is caring for a client who is hyperventilating. The nurse recall the client is at risk for what? a. Respiratory acidosis b. Respiratory alkalosis c. Respiratory compensation d. Respiratory decompensation

B. Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess carbon dioxide retained in the lungs from conditions such as hypoventilation or COPD. Respiratory compensation and decompensation are terms not associated with this situation

1. A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? a. Bradycardia b. Restlessness c. Constricted pupils d. Clubbing of the fingers

B. Restlessness Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia

An older client presents to the emergency department with a 2-day history of cough, pain, wheezing, and dyspnea. The medical record states the client has not received the pneumococcal vaccine. While collaborating with the interprofessional team, which one of these medications does the nurse anticipate the health care provider will recommend as the priority? Corticosteroid Beta agonist Pneumococcal vaccine Antibiotic

Beta agonist The priority medication the nurse would expect the HCP to order is a beta-2 agonist or bronchodilator to help decrease bronchospasm and wheezing. This medication allows for adequate oxygenation by relaxing bronchial smooth muscle in the airways, and acts quickly to maintain airway patency.A corticosteroid will decrease airway swelling but takes many hours to days to become effective. A diagnosis of pneumonia has not been validated. However, if documented, the client should receive pneumococcal vaccine as an inpatient The anti-infective medication may be ordered after the cause of the symptoms is determined, but restoring adequate airway patency and reducing dyspnea take priority.

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which respiratory modality does the nurse suggest to the interdisciplinary team as an alternative to mechanical ventilation? Oropharyngeal airway Bi-level positive airway pressure (BiPAP) Non-rebreather mask with 100% oxygen Positive end-expiratory pressure (PEEP)

Bi-level positive airway pressure (BiPAP) The nurse suggests bi-level positive airway pressure (BiPAP) because this type of ventilation provides noninvasive pressure support ventilation by nasal mask or facemask rather than by endotracheal intubation. Generally, it used for clients with sleep apnea but can also be used for clients with respiratory muscle fatigue or impending respiratory failure to avoid more invasive ventilation methods; this may provide short-term relief of an acute problem.An oropharyngeal airway is used to prevent the tongue from occluding the airway or the client from biting the endotracheal tube. A non-rebreather mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas-exchange problem. This modality is "dialed in" on the mechanical ventilator.

1. The nurse is reviewing the client's health history. With which diagnosis is a client most likely to exhibit hemoptysis? a. Anemia b. Pneumonia c. Tuberculosis d. Leukocytosis

C Tuberculosis Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but the sputum usually is yellow, not bloody. Leukocytosis is increased white blood cells, it does not cause hemoptysis

1. A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer

C. Administer oxygen using a face mask The client is exhibiting the classic signs and symptoms associated with the postoperative complication of pulmonary embolus. Initially oxygen should be administered to increase the amount of oxygen being delivered to the pulmonary capillary bed. Obtaining the vital signs should be done after oxygen therapy is instituted. The client is n not experiencing a cardiac arrest, and therefore a code should not be initiated. After more definitive medical intervention, deep breathing and coughing or use of an incentive spirometer may be done to prevent or treat atelectasis

1. A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? a. Hypertension b. Tenacious sputum c. Altered mental status d. Slowed rate of breathing

C. Altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of cardiac hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing is fast and shallow

1. A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? a. An elevated pH, elevated PCO2 b. A decreased pH, elevated PCO2 c. An elevated pH, decreased PCO2 d. A decreased pH, decreased PCO2

C. An elevated pH, decreased PCO2 In respiratory alkalosis the pH level is elevated because of the loss of hydrogen ions; the PCO2 level is low because the carbon dioxide is lost through hyperventilation. An elevate pH, elevated PCO2 is partially compensated metabolic alkalosis. A decreased pH, elevated PCO2 is respiratory acidosis. A decreased pH, decreased PCO2 is metabolic acidosis with some compensation

1. A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time? a. Prepare the client for emergency surgery. b. Facilitate the client's verbal communication. c. Assess the client's response to the interventions. d. Maintain sterility of the ventilation system that is being used.

C. Assess the client's response to the interventions. If a client is not responding to interventions, the plan must be changed to support respiration. Preparing the client for emergency surgery is presumptive; there are insufficient data to conclude that surgery is necessary. Endotracheal intubation does not permit verbal communication. Maintaining sterility of the ventilation system that is being used is important, but not the priority

1. A client reports a cold and severe cough lasting for several minutes accompanied by frequent exhaustion. The nurse observes a "whooping" sound at the end of the cough. Which organism may responsible for this condition in the client? . Coronaviruses b. Bacillus anthracis c. Bordetella pertussis d. Group A beta-hemolytic Streptococcus

C. Bordetella pertussis Pertussis is a respiratory infection caused by the Bordetella pertussis bacterium. In the paroxysmal stage of pertussis, the client may have a cold and severe cough that lasts for several minutes accompanied by frequent exhaustion. A distinct "whooping" sound is heard at the end of the cough - more common in children than adults. Coronaviruses cause severe acute respiratory syndrome. Bacillus anthracis causes inhalation anthrax. Group A beta-hemolytic streptococcus causes peritonsillar abscess.

1. A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? a. Report of pain when taking deep breaths b. Client is observed splinting the fractured site c. Diminished breath sounds on the affected side d. Bowel sounds are auscultated in the lower chest

C. Diminished breath sounds on the affected side Fractured ribs may penetrate the pleura and lung, allowing air to fill the pleural space and collapse the lung, causing diminished breath sounds. This is a complication of fractured ribs. Reports of pain when taking deep breaths is an expected response to tissue trauma caused by a fractured rib. Observing the client splinting the fracture site is an expected response to tissue damaged caused by a fractured rib. Bowel sounds auscultated in the lower chest suggest rupture of the diaphragm, not fracture ribs

1. A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? a. The client's pneumonia is continually improving. b. Oxygen concentration up to 44% can be obtained. c. Mechanical ventilation may be required next. d. Oxygen via nasal cannula at 6 L per minute

C. Mechanical ventilation may be required next. A nonrebreathing mask is used when the client requires higher oxygen concentration and the condition is worsening. If the nonrebreathing mask does not improve oxygen saturation, the next steps to improving gas exchange and oxygenation are intubation and mechanical ventilation. Oxygen concentrations up to 90% can be achieved. Nasal cannula would not be advised, as the client requires more oxygen that can be delivered through this method.

1. The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, PCO2 of 50 mm Hg, HCO3 of 58 mEq/L, and a serum potassium level of 3.8 mEq/L. The nurse concludes that the findings support what diagnosis? a. Hypocapnia b. Hyperkalemia c. Metabolic alkalosis d. Respiratory acidosis

C. Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg, hypercapnia, no hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mE1/L. With respiratory acidosis the pH will be less than 7.35

1. A nurse is caring for client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

C. Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increase carbon dioxide level leads to respiratory acidosis. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression of excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid

1. A client with COPD has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

C. Respiratory acidosis The normal blood pH range is 7.35 to 7.45; therefore a blood pH of 7.25 indicates acidosis. The parameter for respiratory function i s CO2 and the acceptable range of PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated

1. A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? a. Bradycardia b. Flushed face c. Unilateral chest pain d. Decreased blood pressure

C. Unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence the blood pressure

An adult resident with a C 6 spinal cord injury who resides in a long-term-care facility develops new onset of confusion, agitation and shouting, "Get out of here! You're trying to kill me!" Which action will the nurse take first? Check the resident's oxygen saturation. Do a complete neurologic assessment. Administer the prescribed PRN lorazepam. Perform a mini mental status exam.

Check the resident's oxygen saturation. The nurse's first action is to assess the client's oxygenation by checking the pulse oximetry. Determining the cause of the confusion is the primary goal of the RN. A common reason for sudden confusion in adult clients and those with spinal cord injury that may weaken respiratory muscles is hypoxemia caused by undiagnosed pneumonia or pulmonary embolism.A complete neurologic examination may give the RN other indicators of the cause for the client's confusion and agitation, but this will take several minutes to complete. Administering lorazepam may mask symptoms of hypoxemia, delaying treatment. Benzodiazepine medications may cause a paradoxical reaction, or opposite effect, in some older clients, enhancing agitation. A mini mental status exam determines cognitive function and may give direction to the diagnosis of Alzheimer's or traumatic brain injury.

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? The left chest caves in on inspiration and "puffs out" on expiration. Chest asymmetry and jugular vein distention are present. The left lung field is dull to percussion with crackles present on auscultation. The client has bloody sputum and wheezes.

Chest asymmetry and jugular vein distention are present. Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal.Flail chest is generally the result of fractures of at least two neighboring ribs in two or more places and is manifested by paradoxical chest movement. This consists of "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94% Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications

The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients? Client with diabetic ketoacidosis (DKA) Client with atrial fibrillation Client with aspiration pneumonia Client with acute kidney failure

Client with aspiration pneumonia The nurse will carefully watch the client with aspiration pneumonia for signs of ARDS. Acute Respiratory Distress Syndrome also called noncardiac-associated bilateral pulmonary edema is characterized by widespread inflammation in the lungs. Aspiration of acidic gastric contents promotes inflammation and is a risk for ARDS.Clients with DKA may develop metabolic acidosis, but do not typically ARDS, which develops as a result of lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation? Client who requires suctioning of oral secretions Client with hypoventilation and decreased breath sounds Client with O2 saturation of 90% Client with thick, purulent secretions and crackles

Client with hypoventilation and decreased breath sounds The nurse plans for immediate intubation for the client who demonstrates hypoventilation and has decreased breath sounds.There is no indication that the client with difficulty handling oral secretions or who has purulent sputum has hypoxemia or airway obstruction interfering with swallowing. Suctioning of oral secretions, rather than intubation, is indicated while continuing to monitor for hypoxemia, aspiration, and pneumonia. Intubation may be indicated for the client with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? Client with bacterial pneumonia and a cough productive of green sputum Client with neutropenia and pneumonia caused by Candida albicans Client with possible H5N1 influenza who currently has epistaxis Client with right empyema who has a chest tube and a fever of 103.2° F (39.6°C)

Client with possible H5N1 influenza who currently has epistaxis A client with possible tuberculosis or H5N1 avian influenza would be admitted to the negative-airflow room to prevent airborne transmission of organisms from the client room to other clients/staff and areas of the hospital. A client with bacterial pneumonia does not require a negative-airflow room but should have airborne or Droplet Precautions in place. A client with neutropenia may be in a regular room with an emphasis on handwashing. The client with a right empyema who also has a chest tube and a fever would have Contact Precautions in place but does not require a negative-airflow room.

The registered nurse receives report on four clients on a medical-surgical unit. Which of these clients will the charge nurse assign to the LPN/LVN? Client with group A beta-hemolytic streptococcal pharyngitis who has stridor Client with pulmonary tuberculosis who is receiving multiple medications Client with sinusitis who has just arrived after having endoscopic sinus surgery Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

Client with pulmonary tuberculosis who is receiving multiple medications The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Each state designates which tasks may be safely delegated and assigned to nursing team members. Depending on the state's nurse practice act, licensed practical/vocational nurses (LPNs/LVNs) and technicians may be trained and undergo competency verification related to the skill of peripheral IV insertion and assistance with infusions. The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks (Infusion Nurses Society [INS], 2016; Weinstein & Hagle, 2014).Stridor, a harsh respiratory sound, is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful swallowing and respiratory assessment and monitoring by the RN.

The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia, typical to older adults, does the nurse assess? Bradycardia Confusion Eupnea Pale skin

Confusion The most common symptom of pneumonia in the older adult client is acute confusion from hypoxia. Fever and cough may be absent, but hypoxemia is often present. Symptoms of pneumonia include flushing, not pale skin, anxiety, chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, not bradycardia, dyspnea, tachypnea not eupnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Crackles, wheezing may be heard over areas of fluid, decreased breath sounds are present and wheezing may be heard where the airways are narrowed by exudate.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? Completing the antibiotic medication regimen Taking pain medications every 4 to 6 hours Contacting the health care provider (HCP) if drooling occurs Using warm saline gargles and irrigations

Contacting the health care provider (HCP) if drooling occurs The most important point to teach the client is to notify the HCP if signs of drooling develop. Clients with peritonsillar abscesses are at risk for airway obstruction due to swelling, manifested by drooling. It is also important to tell the client to complete the antibiotics to treat the infection, and to adhere to comfort measures such as analgesic medications and saline gargles, but these are not priority issues.

1. A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent? a. Incisional pain b. Wound dehiscence c. Anastomosis leakage d. Pulmonary embolism

D. Pulmonary embolism Immobility contributes to venous stasis, which can cause deep vein thrombosis and pulmonary embolism. Insufficient mobility does not contribute to incisional pain; incisional pain contributes to immobility. Stressors commonly associate with wound dehiscence include obesity, infection, and poor wound healing, not immobility. Anastomosis leakage occurs when gastrointestinal contents leak into the abdominal cavity; it is caused by leakage around, or separation of sutures or staples where the stomach is stapled or the loop of the jejunum is anastomosed to a new outlet from the stomach, or where it is attached to the proximal jejunum

1. A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? a. Tetany b. Hypercapnia c. Metabolic acidosis d. Respiratory alkalosis

D. Respiratory alkalosis Increased rate and depth of breathing result in excessive elimination of CO2, and respiratory alkalosis can result. Tetany is associated with hypocalcemia. With hyperventilation, CO2 levels will be decreased (hypocapnia), not elevated. Metabolic acidosis results from excess hydrogen ions caused by a metabolic problem, not a respiratory problem

A client with aspiration pneumonia occurring after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? Administer levofloxacin (Levaquin) 500 mg IV. Draw aerobic and anaerobic blood cultures. Give lorazepam (Ativan) as needed for agitation. Refer to social worker for alcohol counseling.

Draw aerobic and anaerobic blood cultures. The nurse would first obtain aerobic and anaerobic cultures in a febrile client for whom antibiotics have been prescribed. Getting cultures to identify the causative organism before initiating an antibiotic could affect the results of the culture and the type of antibiotic used. Levofloxacin, an antibiotic, is a priority intervention, and would be done after cultures are drawn. Unless this client is a danger to self or staff, giving lorazepam (Ativan) for agitation is not the first action. Other interventions to help control the agitation may be tried, such as decreasing stimulation. A referral to social work for alcohol counseling will be initiated before the time of discharge, but is not the immediate concern.

The nurse on a medical surgical unit is caring for an adult client who has type 2 diabetes and is now admitted for pneumonia. The nurse must ensure the Joint Commission's National Client Safety Goals for this client are met and therefore follows up on which of these? Hemoglobin A1C Culture and Sensitivity report Evaluating pneumonia vaccine status Ensuring education to cough into the upper sleeve

Evaluating pneumonia vaccine status The Joint Commission's National Client Safety Goals (NPSGs) and core measures are client-safety oriented and recommends that all inpatients need to have their pneumonia vaccination status evaluated and, if needed, be vaccinated during that admission. It is important to provide diabetes education and assist the client in understanding the role of A1C in diabetes management, but that is not a core measure related to this situation. A culture and sensitivity may be performed, but is not a requirement or core measure. Coughing into the upper sleeve is a technique the center for disease control (CDC) recommends to prevent transmission and reduce the spread of disease.

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? Inadequate nutrition related to food-drug interactions with anticoagulant therapy Risk for infection related to leukocytosis Hypoxemia related to ventilation-perfusion mismatch Insufficient knowledge related to the cause of PE

Hypoxemia related to ventilation-perfusion mismatch The client problem given priority by the nurse is hypoxia related to ventilation-perfusion mismatch. Restoring adequate oxygenation and tissue perfusion takes priority. Obstruction of blood flow through the pulmonary artery or branches impairs ability of the alveolus to deliver oxygen to the left side of the heart; the resulting hypoxemia may be profound. Initially the client breathes more rapidly and eliminates CO2 causing respiratory alkalosis. A large PE causes hypoventilation and prolonged hyperventilation causes muscle fatigue and hypoventilation; hypoventilation leads to respiratory acidosis.Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis, elevated WBC count, an expected response to lung inflammation. Leukopenia places clients at risk for infection, but neither is the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability are ensured.

The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)? Keep the head of the bed elevated. Teach about incentive spirometer use. Monitor vital signs every 5 minutes. Adjust the nasal oxygen flow rate.

Keep the head of the bed elevated. Positioning clients is included in UAP education and scope of practice and can be delegated.Client teaching is an activity performed by the professional nurse. Although taking vital signs is an activity of the UAP, monitoring a potentially unstable client is done by the RN. Adjusting oxygen flow rates requires complex decision making and should be done by the RN.

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first? Check the ventilator alarm settings. Assess the set tidal volume. Listen to the client's breath sounds. Call the respiratory therapist.

Listen to the client's breath sounds. The nurse will first listen to the client's breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.The nurse is behind the assessment with the client, not with the ventilator or ventilator settings. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse's first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? Teach the client to avoid using dental floss. Monitor the platelet count daily. Ensure adequate staffing for the unit. Notify radiology of an impending scan.

Monitor the platelet count daily. Daily platelet counts are a safety priority in assessing for heparin induced thrombocytopenia, a potential side effect of heparin.Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. The nurse would work with the manager to ensure adequate staffing but this is not a priority. Notifying radiology of needed scans is not a safety priority.

A client who has recently relocated to the United States from Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? Contact the health care provider for tuberculosis (TB) medications. Perform a TB skin test. Place a respiratory mask on the client. Test all family members for TB.

Place a respiratory mask on the client. The nurse's first action is to place a respiratory mask on the client. The concern is that this client has a high risk for TB having recently immigrated from overseas. Client with symptoms consistent with TB should be considered infectious until the disease is ruled out. Requesting medications for TB is not appropriate until the client has been evaluated and a diagnosis has been made. Performing a TB test will be important, but this is not the top priority. Tell the client that results will not be available for at least 48 hours after the test is administered. Further testing of this client needs to be completed and a diagnosis made before family members are tested.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? Ensures that the client is wearing a mask Informs the visitor that the client cannot receive visitors at this time Provides a particulate air respirator to the visitor Provides the visitor with a surgical mask

Provides the visitor with a surgical mask Because the visitor is entering the client's isolation environment, the visitor must wear a mask. The client typically must wear a mask only when he or she is outside of an isolation environment. Turning the visitor away is inappropriate and unnecessary. It would not be necessary for the visitor to wear an air respirator which is typically used for TB, H5N1 influenza, or SARS.

The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis? Providing frequent explanations and reassurance Keeping the lights on to promote orientation Administering sedation Providing television or radio for stimulation

Providing frequent explanations and reassurance Clients with ICU psychosis need frequent, repeated explanations and reassurance. ICU psychosis or delirium can occur in clients undergoing mechanical ventilation in ICUs. It can also be minimized by encouraging sleep, and keeping to a regular routine.Keeping the lights on or providing TV or radio will not encourage sleep. Rather, these activities provide stimulation. Sedation can promote confusion and disorientation. It should be used when necessary to promote oxygenation and compliance with the ventilator.

When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety? Remain with the client and provide oxygen in a calm manner. Have the client breathe into a brown paper bag using pursed lips. Offer the client a mild sedative. Allow a family member to remain in the room.

Remain with the client and provide oxygen in a calm manner. The priority nursing intervention is to correct hypoxemia, the underlying cause of anxiety. The nurse will stay with the client and provide oxygen in a calm manner. Anxiety, agitation, tachycardia, and restlessness are early symptoms of hypoxemia, which occurs with a PE. Oxygen will help to alleviate this problem. Remaining with the client in distress is also appropriate.Rebreathing from a brown paper bag is an intervention that increases PaCO2 during hyperventilation, as in a panic attack; it will not provide needed oxygen and tissue perfusion. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation and may delay appropriate treatment.

The nurse is preparing to assess an adult client who was just admitted with pertussis. Which symptom does the nurse anticipate finding in this client? "Whooping" after a cough Hemoptysis Mild cold-like symptoms Severe coughing spasms

Severe coughing spasms Clients with pertussis will have severe coughing spasms. Paroxysms of coughing will often be followed by changes in color and/or vomiting. Adults do not usually have the characteristic whooping sound associated with coughing exhibited by children with pertussis. Hemoptysis may occur after the acute phase when changes in the respiratory mucosa occur. Mild, cold-like symptoms occur in the initial stages of pertussis and generally do not require hospitalization.

An elderly client is admitted to the emergency department (ED) with symptoms of possible seasonal influenza accompanied by vomiting and high fever. Which of these actions is the nurse's first priority? Ensure that ED staff members receive oseltamivir (Tamiflu). Administer IM influenza vaccination. Place the client in a negative air pressure room. Start an IV line and begin intravenous hydration.

Start an IV line and begin intravenous hydration. The nurse's first priority is to start an IV line and begin intravenous hydration. Elderly clients with influenza symptoms can develop dehydration quickly because of fever, vomiting and possible diarrhea. Initiating intravenous rehydration is a priority to maintain tissue perfusion. The ED staff would have received annual seasonal influenza vaccine, however if not, they can be given antiviral agents. A negative airflow room is not required in the ED, however a mask would be worn. The seasonal influenza vaccine is designed to prevent influenza. This client already is infected with influenza and if not vaccinated, can receive the vaccine prior to discharge but this is not the priority as it takes weeks for full immunity to develop

The nurse is caring for a client with severe acute respiratory syndrome (SARS). What is the most important infection control precaution that the nurse takes when preparing to suction this client? Keeping the door to the client room closed Performing oral care after suctioning the oropharynx Washing hands and donning gloves prior to the procedure Wearing a disposable particulate mask respirator

Wearing a disposable particulate mask respirator The most important infection control precaution the nurse must take before suctioning a client is to wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms. The door to the room needs to be closed during care of the client with SARS and other instances of airborne precautions. The immediate concern while suctioning is spread of infection to the nurse who is at risk for infection due to aerosolized secretions. It is unlikely organisms could aerosolize as far as the door. Performing oral care is a part of the oral suctioning procedure process. Washing hands and donning gloves are necessary, but not the most important measure

1. A client's arterial blood gas report indicates that pH is 7.25, PCO2 is 60 mm Hg, and HCO3 is 26 mEq/L. Which client should the nurse consider is most likely to exhibit these blood gas results? a. A 65-year-old with pulmonary fibrosis b. A 24-year-old with uncontrolled type 1 diabetes c. A 45-year-old who has been vomiting for 3 days d. A 54-year-old who takes sodium bicarbonate for indigestion

a. A 65-year-old with pulmonary fibrosis The low pH and elevated PCO2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impeded the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the body. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely with experience metabolic alkalosis from an excess of base bicarbonate

1. An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic acidosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis, not alkalosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis

1. The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the result of which laboratory test to evaluate the client for hypoxia? a. Red blood cell count b. Sputum culture c. Arterial blood gas d. Total hemoglobin

c. ABG Red blood cell count, sputum, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

1. The nurse is caring for a client with the following ABG values: PO2 89 mm HG, PCO2 35 mm Hg, and pH or 7.37. These findings indicate that the client is experiencing which condition? a. Respiratory alkalosis b. Poor oxygen perfusion c. Normal acid-base balance d. Compensated metabolic acidosis

c. Normal acid-base balance All data are within expected limits; PO2 is 80 to 100 mm Hg, PCO2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen is within the expected limits of 80 to 100 mm Hg. With metabolic acidosis, the pH is less than 7.35. With respiratory alkalosis, the pH is greater than 7.45

1. The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis? a. PCO2: 49, HCO3: 32, pH: 7.50 b. PCO2: 26, HCO3: 20, pH: 7.52 c. PCO2: 54, HCO3: 28, pH: 7.30 d. PCO2: 28, HCO3: 18, pH: 7.28

d. PCO2: 28, HCO3: 18, pH: 7.28 Decreased pH and bicarbonate values reflect metabolic acidosis (seen in DKA); a decreased PCO2 values indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased PCO2 value indicates compensatory hypoventilation. Increased pH and decreased PCO2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased PCO2 values reflect hypoventilation and respiratory acidosis