Nursing III test 2

The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which finding would indicate that the oxygen level was adequate? 1 A PO2 of 80 mm Hg 2 A PO2 of 60 mm Hg 3 A PO2 of 50 mm Hg 4 A PO2 of 45 mm Hg

Answer: 1 Rationale: The normal PO2 level is 80 to 100 mm Hg. Options 2, 3, and 4 are low values and do not indicate adequate oxygen levels. Priority Nursing Tip: The normal arterial blood gas pH value is 7.35 to 7.45.

47. A home care nurse assesses a client with chronic obstructive pulmonary disease (COPD) who is complaining of increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and the client's respiratory rate is 22 breaths per minute. The appropriate nursing action is to: 1 Determine the need to increase the oxygen. 2 Reassure the client that there is no need to worry. 3 Conduct further assessment of the client's respiratory status. 4 Call emergency services to take the client to the emergency department.

Answer: 3 Rationale: Obtaining further assessment data is the appropriate nursing action. Oxygen is not increased without the approval of the physician, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is "no need to worry" is inappropriate. Calling emergency services is a premature action

A nurse reviews the blood gas results of a client with guillain barre syndrome. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurses findings? 1. ph 7.50, pco2 52 mm Hg 2. Ph 7.35 pco2 40 mm hG 3. PH 7.25, pco2 50 mm Hg 4. ph 7.50 pco2 30 mm hG

answer: 3 The normal pH is 7.35 -7.45 the normal pco2 is 45-45 in respiratory acidosis the ph is down and the pco2 is up option 1 ids an alkalotic ondition, option 2 is normal values, option 4 ids respiratory alkalosis

The nurse assesses a male client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing? A-Diaphragmatic breathing B-Use of accessory muscles C-Pursed-lip breathing D-Controlled breathing

answer: B The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A Dyspnea B Bradypnea C Bradycardia D Decreased respirations

answer: a The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: A-1 minute B-5 seconds C-10 seconds D-30 seconds

answer: c Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds

Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: A Dyspnea B Chest pain C A bloody, productive cough D A cough with the expectoration of mucoid sputum

answer: d One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.

A nurse understands that excessive use of oral antacids containing bicarb can result in which acid base disturbance? 1. respiratory alkalosis 2.respiratory acidosis 3. metabolic acidosis 4. metabolic alkalosis

answer:4 increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates or lactates. excessive use of oral antacids containing bi carbonate can cause metabolic alkalosis

A client at risk for respiratory failure is receiving oxygen via nasal cannula at 6 L per minute. Arterial blood gas (ABG) results indicate: pH 7.29, PCO2 49 mm Hg, PO2 58 mm Hg, HCO3 18 mEq/L. The nurse anticipates that the physician will prescribe which of the following for respiratory support? 1 Intubation and mechanical ventilation 2 Adding a partial rebreather mask to the current prescription 3 Keeping the oxygen at 6 L per minute via nasal cannula 4 Lowering the oxygen to 4 L per minute via nasal cannula

Answer: 1 Rationale: If respiratory failure occurs and supplemental oxygen cannot maintain acceptable PaO2 and PaCO2 levels, endotracheal intubation and mechanical ventilation are necessary. The client is exhibiting respiratory acidosis, metabolic acidosis, and hypoxemia. Lowering or keeping the oxygen at the same liter flow will not improve the client's condition. A partial rebreather mask will raise CO2 levels even further

A nurse is preparing to administer oxygen to a client who has chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse checks to see that the oxygen flow rate is prescribed at: 1 2 to 3 liters per minute 2 4 to 5 liters per minute 3 6 to 8 liters per minute 4 8 to 10 liters per minute Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory

Answer: 1 Rationale: In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client loses the respiratory drive, and respiratory failure results. Thus the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute.

A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg, a partial pressure of oxygen of 79 mm Hg, and a bicarbonate level of 19 mEq/L. The nurse interprets that the client is experiencing: 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

Answer: 1 Rationale: Metabolic acidosis occurs when the pH falls to less than 7.35 and the bicarbonate level falls to less than 22 mEq/L. With respiratory acidosis, the pH drops to less than 7.35 and the carbon dioxide level rises to more than 45 mm Hg. With respiratory alkalosis, the pH rises to more than 7.45 and the carbon dioxide level falls to less than 35 mm Hg. With metabolic alkalosis, the pH rises to more than 7.45 and the bicarbonate level rises to more than 27 mEq/L.

The nurse is sending an arterial blood gas (ABG) specimen to the laboratory for analysis. Which of the following pieces of information should the nurse write on the laboratory requisition? Select all that apply. r 1 Ventilator settings r 2 A list of client allergies r 3 The client's temperature r 4 The date and time the specimen was drawn r 5 Any supplemental oxygen the client is receiving r 6 Extremity from which the specimen was obtained

Answer: 1, 3, 4, 5 Rationale: An ABG requisition usually contains information about the date and time the specimen was drawn, the client's temperature, whether the specimen was drawn on room air or using supplemental oxygen, and the ventilator settings if the client is on a mechanical ventilator. The client's allergies and the extremity from which the specimen was drawn do not have a direct bearing on the laboratory results.

The nurse is interviewing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which nursing diagnosis would be appropriate for the client? 1 Deficient Knowledge related to COPD 2 Disturbed Body Image related to a neurological deficit 3 Impaired Verbal Communication related to a physical barrier 4 Ineffective Coping related to an inability to handle a situational crisis

Answer: 3 Rationale: A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support options 1, 2, and 4.

The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, the nurse should plan time for which activity after the arterial blood is drawn? 1 Holding a warm compress over the puncture site for 5 minutes 2 Encouraging the client to open and close the hand rapidly for 2 minutes 3 Applying pressure to the puncture site by applying a 2 2 gauze for 5 minutes 4 Having the client keep the radial pulse puncture site in a dependent position for 5 minutes

Answer: 3 Rationale: Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

A client with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. The nurse implements which of the following for this procedure to be most effective? 1 Obtains baseline arterial blood gases 2 Obtains baseline pulse oximetry levels 3 Applies the mask to the face with a snug fit 4 Encourages the client to remove the mask frequently for coughing and deep breathing exercises

Answer: 3 Rationale: The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.

The nurse has received her client assignment for the day. Which client should the nurse care for first? 1 A client with a wound infection who has a temperature of 100.4_ F 2 A client with a deep vein thrombosis who reports bleeding gums when brushing the teeth 3 A client who had a right arm casted 12 hours ago who is complaining of numbness in the fingers 4 A client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 22 beats per minute

Answer: 3 Rationale: The client with a cast who experiences numbness in the fingers should be seen first because this could be a symptom of compartment syndrome. Compartment syndrome creates an emergency situation when it does occur. Within 4 to 6 hours after the onset of compartment syndrome, neurovascular and muscle damage are irreversible if treatment is not provided. The limb can become useless in 24 to 48 hours. It would be expected that the client with a wound infection will have an elevation in body temperature. A client on anticoagulant therapy for treatment of a deep vein thrombosis who experiences bleeding gums when brushing teeth should be evaluated but is not the priority. A respiratory rate of 22 breaths per minute in the client with COPD is considered normal.

302. The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client demonstrates which of the following? 1 Breathes in and then holds the breath for 30 seconds 2 Loosens the abdominal muscles while breathing out 3 Inhales with pursed lips and exhales with the mouth open wide 4 Breathes so that expiration is two to three times as long as inspiration

Answer: 4 Rationale: Chronic obstructive pulmonary disease is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD.

A client having a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

Answer: 4 Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.

A client is to have arterial blood gases drawn. While the nurse is performing Allen's test, the client says to the nurse, "What are you doing? No one else has done that!" The nurse makes which therapeutic response to the client? 1 "I assure you that I am doing the correct procedure. I cannot account for what others do." 2 "This step is crucial to safe blood withdrawal. I would not let anyone take my blood until they did this." 3 "Oh? You have questions about this? You should insist that they all do this procedure before drawing up your blood." 4 "This is a routine precautionary step that simply makes certain your circulation is intact before a blood sample is obtained."

Answer: 4 Rationale: Allen's test is performed to assess collateral circulation in the hand before drawing a radial artery blood specimen. The therapeutic response provides information to the client. Option 1 is defensive and nontherapeutic in that it offers false reassurance. Option 2 identifies client advocacy, but it is overly controlling and aggressive, and undermines treatment. Option 3 is aggressive, controlling, and nontherapeutic in its disapproving stance.

A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse visits the client and most importantly plans teaching strategies that are designed to: 1 Promote membership in support groups. 2 Encourage the client to become a more active person. 3 Identify irritants in the home that interfere with breathing. 4 Improve oxygenation and minimize carbon dioxide retention.

Answer: 4 Rationale: Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction. Improving oxygenation and minimizing carbon dioxide retention are the primary goals. The other options are interventions that will help with the achievement of this primary goal

798 A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse visits the client and most importantly plans teaching strategies that are designed to: 1 Promote membership in support groups. 2 Encourage the client to become a more active person. 3 Identify irritants in the home that interfere with breathing. 4 Improve oxygenation and minimize carbon dioxide retention.

Answer: 4 Rationale: Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction. Improving oxygenation and minimizing carbon dioxide retention are the primary goals. The other options are interventions that will help with the achievement of this primary goal.

The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2 L per minute. The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse would initially: 1 Determine the need to increase the oxygen. 2 Call emergency services to come to the home. 3 Reassure the client that there is no need to worry. 4 Collect more information about the client's respiratory status.

Answer: 4 Rationale: Completing an assessment and collecting additional information regarding the client's respiratory status is the initial nursing action. The oxygen is not increased without validation of the need for further oxygen and the approval of the physician, especially because clients with COPD can retain carbon dioxide. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry.

A client with chronic obstructive pulmonary disease (COPD) has a knowledge deficit related to the positions used to breathe more easily. The nurse teaches the client to assume which of the following positions? 1 Sit bolt upright in bed with the arms crossed over the chest. 2 Lie on the side with the head of the bed at a 45-degree angle. 3 Sit in a reclining chair tilted slightly back with the feet elevated. 4 Sit on the edge of the bed with the arms leaning on an overbed table.

Answer: 4 Rationale: Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Option 1 restricts the movement of the anterior and posterior walls of the lung, and option 2 restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.

Which of the following arterial blood gases (ABGs) should the nurse anticipate in the client with a nasogastric tube attached to continuous suction? 1 pH 7.25 PCO2 55, HCO3 24 2 pH 7.30 PCO2 38, HCO3 20 3 pH 7.48 PCO2 30, HCO3 23 4 pH 7.49 PCO2 38, HCO3 30

Answer: 4 Rationale: The anticipated arterial blood gas in the client with a nasogastric tube to continuous suction is metabolic alkalosis resulting from loss of acid. In uncompensated metabolic alkalosis the pH will be elevated (greater than 7.45), bicarbonate will be elevated (greater than 27 mEq/mL), and the PCO2 will most likely be within normal limits (35 to 45 mm Hg). Therefore options 1, 2, and 3 are incorrect.

63 The client's arterial blood gas (ABG) results are pH 7.34, PaCO2 50, HCO3 24, PaO2 87. Which intervention should the nurse implement first? 1. Have the client turn, cough, and deep breathe. 2. Place the client on oxygen via nasal cannula. 3. Check the client's pulse oximeter reading. 4. Notify the HCP of the ABG results.

answer 1 1. These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe. 2. The PaO2 level is within normal limits, 80 to 100. Administering oxygen is not the first intervention. 3. The nurse knows the arterial blood gas oxygen level, which is an accurate test. The pulse oximeter only provides an approximate level. 4. This is not the first intervention. The nurse can intervene to treat the client before notifying the HCP. Content - Medical/Surgical:

The client diagnosed with abdominal pain of unknown etiology has a nasogastric tube draining green bile and reports abdominal pain of 8 on a scale of 1 to 10. The client's arterial blood gas values are pH 7.48, PaO2 98, PaCO2 36, HCO3 28. Which intervention should the nurse implement based on the client's ABGs? 1. Assess the client to rule out any complications secondary to the client's pain. 2. Determine the last time the client was medicated for abdominal pain. 3. Check the amount of suction on the client's nasogastric tube. 4. Administer intravenous sodium bicarbonate to the client 19

answer 3 1. The client is in metabolic alkalosis, so this intervention is not appropriate for the client's ABGs. 2. The client is in metabolic alkalosis, so this intervention is not appropriate for the client's ABGs. 3. The ABG indicates metabolic alkalosis, which could be caused by too much hydrochloric acid being removed via the N/G tube. Therefore, the nurse should check the N/G wall suction. 4. Sodium bicarbonate is administered for metabolic acidosis not metabolic alkalosis

15. W hich of the following nursing interventions should the nurse take after assessing slight respiratory alkalosis on the arterial blood gas analysis of a pregnant client? 1. N otify the physician 2. R epeat the test in 1 hour 3. N o action needed 4. C onsult respiratory therapy

answer 3 during pregnancy, a slight respiratory alkalosis occurs, resulting from the 30-40% increase in tidal volume. The increased PaO2 and the decreased PCO2 of the maternal circulation facilitate the removal of the carbon dioxide from the fetal circulation. The decreased PCO2 of the mother is compensated by the increased renal excretion of the bicarbonate permitting the arterial pH to remain in the normal range. No action is necessary.

18. A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45. Which of the following is the most appropriate nursing intervention? 1. A dminister a sedative 2. P lace client in left lateral position 3. P lace client in high-Fowler's position 4. A ssist the client to breathe into a paper bag

answer 3. T he client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high- Fowler's position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.

8. A client with pulmonary edema is currently receiving 6 L/min of oxygen per nasal cannula. The most recent arterial blood gas (ABG) results indicate the following: pH 5 7.30, pCO2 5 50 mm Hg, pO2 5 56 mm Hg, HCO3 5 24 mm Hg. The nurse anticipates that the physician will order which of the following? 1. C hange nasal cannula to face mask at 6 L/min oxygen 2. A dd one ampule of sodium bicarbonate to the client's current intravenous fluids 3. C hange nasal cannula to partial rebreather mask at 8 L/min oxygen 4. Intubate the client and place on mechanical ventilation

answer 4 4. T he client is exhibiting respiratory acidosis with severe hypoxemia. Intubation and mechanical ventilation are warranted in this situation. Changing the oxygen delivery system to a mask would not correct the hypoxemia. Changing the oxygen delivery system to partial rebreather mask, even with a slight increase in oxygen, would not correct the significant hypoxia, and the rebreather mask would increase the pCO2 retention. Adding sodium bicarbonate to the IV fluids treats a clinical manifestation, not the underlying condition of respiratory distress, and sodium bicarbonate will not correct the hypoxemia.

A nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dysphenic periods. Which of the following positions will the nurse instruct the client to assume? 1. side lying in bed 2. sitting in a recliner chair 3. sitting up in bed 4. sitting on the side of the bed and leaning on an over bed table

answer 4 Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees and standing and leaning against the wall

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: A Promote oxygen intake B Strengthen the diaphragm C Strengthen the intercostal muscles D Promote carbon dioxide elimination

answer : dPursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A Pallor B Low arterial PaO2 C Elevated arterial PaO2 D Decreased respiratory rate

answer b: The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

An oxygen delivery system is prescribed for a client with copd to deliver a precise oxygen concentration. Which of the following types of o2 delivery systems would the nurse anticipate to be prescribed 1. venture mask 2. aerosol mask 3. face tent 4. tracheostomy collar

answer: 1 The venture mask delivers the most accurate o2 concentration. The venture mask is the best o2 delivery system for the client with chronic airflow limitation because it delivers a precise o2 concentration the face tent, the aerosol mask, and the tracheostomy collar are also high flow o2 delivery systems but most often are used to administer high humidity

A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid base imbalance? 1. Respiratory acidosis 2. respiratory alkalosis 3. metabolic acidosis 4. metabolic alkalosis

answer: 1 Rationale: Resp acidosis is most often due to hypoventilation. Chronic respiratory acidosis is most commonly caused by copd. In end stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation perfusion relationships

An unconscious client is admitted to an emergency room. ABG measureents reveal a ph of 7.30, a low bi carbonate level, a normal carbon dioxide level, and a normal oxygen level. An elevated potassium level si also present. THese results indicate the presence of 1. metabolic acidosis 2. respiratory acidosis 3. combined resp/ metabolic acidosis 4. overcompensated respiratory acidosis

answer: 1. metabolic acidosis' an acidotic condition the ph would be low indicating acidosis. IN addition, a low bicarbonate level along with the low pH would indicate a metabolic state.

39 A nurse is assessing a client with chronic airflow limitation and notes that the client has a barrel chest. The nurse interprets t this client has which of the following forms of chronic airflow limitation? 1. chronic obstructive bronchitis 2. emphysema 3. bronchial asthma 4. bronchial asthma and bronchitis

answer: 2 the client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. THese lead to increased anteroposterior diameter, which is referred to as barrel chest. THE client also has dyspnea with prolong expiration and has hyper resonant lungs to percussion

A nurse I caring for a client who is on a mechanical ventilator. Blood gas results indicate a ph of 7.50 and a pco2 of 30 mm hG the nurs ehas determined that the client is experiencing respiratory alkalosis. Which lab value would be noted in this condition? 1. sodium level of 145 meQ/L 2. potassium level of 3.0 3. magnesium level of 2.0 4. phosphorus level of 4.0

answer: 2 Clincial manifestations of respiratory alkalosis include. Headache, tachypnea, parestesias, tetany, vertigo, convlusions, hypokalemia, and hypocalcemia

A nurse is caring for a client hospitalized with acute exacerbation of copd, which of the following would the nurse expect to note on assessment of the client? 1. increased o2 saturation with exercise 2. hypocapnia 3. a hyperinflated chest on x ray film 4. a widened diaphragm noted on chest xx ray film

answer: 3 Clinical manifestations of copd include hypoxemia, hypercapnia, dyspnea on exertion ad at rest, o2 desaturation with exercise, and use of accessory muscles of respiration. CHest xray films reval a hyperinflated chest and a flattened diaphragm if the disease is advanced

The charge nurse on the critical care respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require an immediate intervention by the charge nurse? 1. The client with chronic obstructive pulmonary disease who has a pH 7.34, PaO2 70, PaCO2 55, HCO3 24. 2. The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO2 75, PaCO2 50, HCO3 26. 3. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23. 4. The client with a pneumothorax with a pH 7.41, PaO2 98, PaCO2 43, HCO3 25.

answer: 3 Although these are abnormal ABG values, respiratory acidosis, they are expected in a client with COPD; therefore, the nurse would not need to see this client first. 2. The client with ARDS would be expected to have a low arterial oxygen level; therefore, the nurse would not assess this client first. 3. The ABG shows respiratory alkalosis; therefore, the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temperature. 4. These are normal ABGs; therefore, the nurse would not need to assess this client first.

A nurse is caring for a client with renal failure. Blood gas results indicate a ph of 7.30 a pco2 of 32 mm HG, and a bi carb concentration of 20 meq/ l the nurse has determined that the client is experiencing metabolic acidosis. which of the following lab values would the nurse expect? 1. sodium level of 145 meq/ l 2. magnesium level of 2.0 mg/ dl 3. potassium level of 5.2 meq/ l 4. phosphorus level of 4.0 mg/dl

answer: 3 clinical manifestations of metabolic acidosis include hyperpnea with kussmauls respirations, headache, nausea, vomiting , and diarrhea, fruity smelling breath resulting from improper fat metabolism, cns depression including mental dullness, drowsiness, stupor, and coma, twitching and convulsions, hyperkalemia will occur

16A nurse reviews the abg values of a client. The results indicate resp acidosis. Which of the following values would indicate that this acid base imbalance exists? 1. ph 7. 48 2. pco2 of 32 mm hg 3. ph 7.30 4. hco3 20 meq

answer: 3 IN respiratory acidosis the ph will be lower than normal and the pco2 will be elevated. THe normal ph is 7.35-7.45 the normal pco2 is 35-45 the only option that reflects these conditions is option 3

A nurse reviews abg results of a client and notes the following ph 7.45, pco2 30 and bi carb 22 the nurse analyzes these results as indicating 1. met acidosis compensated 2. met alkalosis uncompensated 3. resp alk compensated 4. resp acidosis uncompensated

answer: 3 The normal ph is 7.35- 7.45 In a resp condition an opposite effect will be seen btween the ph and the pco2 in this situation the ph is at the high end of the normal value and the pco2 is low. In an alkalotic condition the ph is up. There for the values identified in the question indicate a resp alkalosis. Compensation occurs when the ph returns to a normal value. Because the ph is in the normal range at the high end, compensation has occurred.

A nurse is caring for a client with a ng tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which disorder? 1. respiratory acidosis 2. respiratory alkalosis 3. metabolic acidosis 4. metablic alkalosis

answer: 4 Loss of gastric fluid via ng suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? A- Simple mask B-Non-rebreather mask C-Face tent D-Nasal cannula

answer: B A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2

A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: A Area of redness is measured in 3 days and determines whether tuberculosis is present. B Skin test doesn't differentiate between active and dormant tuberculosis infection. C Presence of a wheal at the injection site in 2 days indicates active tuberculosis. D Test stimulates a reddened response in some clients and requires a second test in 3 months.

answer: B The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

A female adult client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: A 15 to 60 seconds B 5 to 20 minutes C 30 to 40 minutes D 45 to 60 minutes

answer: B Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A-Cardiogenic pulmonary edema B-Respiratory alkalosis C-Increased pulmonary capillary permeability D-Renal failure

answer: C ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.

After receiving an oral dose of codeine for an intractable cough, the male client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond? A In 30 minutes B In 1 hour C In 2.5 hours D In 4 hours

answer: a Codeine's onset of action is 30 minutes. Its peak concentration occurs in about 1 hour; its half-life, in 2.5 hours; and its duration of action is 4 to 6 hours.

Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? A Do nothing, because this is an expected finding B Immediately clamp the chest tube and notify the physician C Check for an air leak because the bubbling should be intermittent D Increase the suction pressure so that the bubbling becomes vigorous

answer: a Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration? A Apnea B Anginal pain C Respiratory alkalosis D Metabolic acidosis

answer: a Erythromycin is the drug of choice for treating legionnaires' disease. Rifampin may be added to the regimen if erythromycin alone is ineffective; however, it isn't administered first. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection

A male client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating legionnaires' disease? A Erythromycin (Erythrocin) B Rifampin (Rifadin) C Amantadine (Symmetrel) D Amphotericin B (Fungizone)

answer: a Erythromycin is the drug of choice for treating legionnaires' disease. Rifampin may be added to the regimen if erythromycin alone is ineffective; however, it isn't administered first. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection

Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? A Stridor B Occasional pink-tinged sputum C A few basilar lung crackles on the right D Respiratory rate 24 breaths/min

answer: a Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.

The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? A It helps prevent early airway collapse B It increases inspiratory muscle strength C It decreases use of accessory breathing muscles D It prolongs the inspiratory phase of respiration

answer: a Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

A male client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasmal pneumonia. Despite the different causes of the various types of pneumonia, all of them share which feature? A Inflamed lung tissue B Sudden onset C Responsiveness to penicillin D Elevated white blood cell (WBC) count

answer: a The common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Although most types of pneumonia have a sudden onset, a few (such as anaerobic bacterial pneumonia and mycoplasmal pneumonia) have an insidious onset. Antibiotic therapy is the primary treatment for most types of pneumonia; however, the antibiotic must be specific for the causative agent, which may not be responsive to penicillin. A few types of pneumonia, such as viral pneumonia, aren't treated with antibiotics. Although pneumonia usually causes an elevated WBC count, some types, such as mycoplasmal pneumonia, don't.

A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit: A-Resonant sounds B-Hyperresonant sounds C-Dull sounds D-Flat sounds

answer: a When percussing the chest wall, the nurse expects to elicit resonant sounds — low-pitched, hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they're louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax, they may be normal in children and very thin adults. Dull sounds, normally heard only over the liver and heart, may occur over dense lung tissue, such as from consolidation or a tumor. Dull sounds are thudlike and of medium pitch. Flat sounds, soft and high-pitched, are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.

Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase "a" in ABG value present? A Acid-base balance B Arterial Blood C Arterial oxygen saturation D Alveoli

answer: b A lowercase "a" in an ABG value represents arterial blood. For instance, the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase "A" represents alveolar conditions: for example, PA02 indicates the partial pressure of oxygen in the alveoli.

Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause: A Nasal congestion B Nervousness C Lethargy D Hyperkalemia

answer: b Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Otther adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps.

The nurse in charge formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include: A Drinking more than 1,500 ml of fluid daily B Being overweight C Eating a high-protein snack at bedtime D Eating more than three large meals a day

answer: b Conditions that increase oxygen demands include obesity, smoking, exposure to temperature extremes, and stress. A client with chronic bronchitis should drink at least 2,000 ml of fluid daily to thin mucus secretions; restricting fluid intake may be harmful. The nurse should encourage the client to eat a high-protein snack at bedtime because protein digestion produces an amino acid with sedating effects that may ease the insomnia associated with chronic bronchitis. Eating more than three large meals a day may cause fullness, making breathing uncomfortable and difficult; however, it doesn't increase oxygen demands. To help maintain adequate nutritional intake, the client with chronic bronchitis should eat small, frequent meals (up to six a day).

Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: A Call the physician B Place the tube in bottle of sterile water C Immediately replace the chest tube system D Place a sterile dressing over the disconnection site

answer: b If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to: A Call the physician to reinsert the tube B Grasp the retention sutures to spread the opening C Call the respiratory therapy department to reinsert the tracheotomy D Cover the tracheostomy site with a sterile dressing to prevent infection

answer: b If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation

On auscultation, which finding suggests a right pneumothorax? A Bilateral inspiratory and expiratory crackles B Absence of breaths sound in the right thorax C Inspiratory wheezes in the right thorax D Bilateral pleural friction rub

answer: b In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: A 1 L/min B 2 L/min C 6 L/min D 10 L/min

answer: b Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: A Lips B Mucous membranes C Nail beds D Earlobes

answer: b Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color.

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A A low respiratory rate B Diminished breath sounds C The presence of a barrel chest D A sucking sound at the site of injury

answer: b Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color.

Question 10 An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A Face tent B Venturi mask C Aerosol mask D Tracheostomy collar

answer: b The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

A male patient has a sucking stab wound to the chest. Which action should the nurse take first? A Drawing blood for a hematocrit and hemoglobin level B Applying a dressing over the wound and taping it on three sides C Preparing a chest tube insertion tray D Preparing to start an I.V. line

answer: b The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen? A Limiting fluid B Having the client take deep breaths C Asking the client to spit into the collection container D Asking the client to obtain the specimen after eating Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A Inform the physician B Continue to monitor the client C Reinforce the occlusive dressing D Encourage the client to deep-breathe

answer: b To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

Question 9 Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? A Hypocapnia B A hyperinflated chest noted on the chest x-ray C Increased oxygen saturation with exercise D A widened diaphragm noted on the chest x-ray

answer: b Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated

A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis? A Bronchoscopy B Sputum culture C Chest x-ray D Tuberculin skin test

answer: b answer: b Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A The system is functioning normally B The client has a pneumothorax C The system has an air leak D The chest tube is obstructed

answer: c Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber

For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? A Restricting fluid intake to 1,000 ml per day B Enforcing absolute bed rest C Teaching the patient how to perform controlled coughing D Administering prescribe sedatives regularly and in large amounts

answer: c Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.

A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? A Impaired color discrimination B Increased urinary frequency C Decreased hearing acuity D Increased appetite

answer: c Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be prescribed. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompany diabetes mellitus

Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician? A Dry cough B Hermaturia C Bronchospasm D Blood-streaked sputum

answer: c If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: A Pleural effusion B Pulmonary edema C Atelectasis D Oxygen toxicity

answer: c In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching? A Make inhalation longer than exhalation B Exhale through an open mouth C Use diaphragmatic breathing D Use chest breathing

answer: c In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? A Encouraging the patient to drink three glasses of fluid daily B Keeping the patient in semi-fowler's position C Using a high-flow venturi mask to deliver oxygen as prescribe D Administering a sedative, as prescribe

answer: c The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: A Monitor fluctuations in the water-seal chamber B Clamp the chest tube once every shift C Encourage coughing and deep breathing D Milk the chest tube every 2 hours

answer: c When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention? A-Continue to suction B-Notify the physician immediately C-Stop the procedure and reoxygenate the client D-Ensure that the suction is limited to 15 seconds

answer: c During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated

Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for: A Patients with an acute asthma attack B Patients with narcolepsy C Patients under age 6 D Elderly patients

answer: d Ephedrine is not recommended for elderly patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A pH, 5.0; PaCO2 30 mm Hg B pH, 7.40; PaCO2 35 mm Hg C pH, 7.35; PaCO2 40 mm Hg D pH, 7.25; PaCO2 50 mm Hg

answer: d In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.

A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose? A Leg movement B Finger movement C Lip movement D Fighting the ventilator

answer: d Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: A Alprazolam (Xanax) B Propranolol (Inderal) C Morphine D Albuterol (Proventil)

answer: d The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A Exhale slowly B Stay very still C Inhale and exhale quickly D Perform the Valsalva maneuver

answer: d When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions

A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? A-Activity intolerance related to fatigue B-Anxiety related to actual threat to health status C-Risk for infection related to retained secretions D-Impaired gas exchange related to airflow obstruction

answer: d A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important.

Question 20 A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: A Lung vibrations B Vocal sounds C Breath sounds D Chest movements

answer: d The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say "99," the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. The nurse assesses breath sounds during auscultation

A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? A Nausea or vomiting B Abdominal pain or diarrhea C Hallucinations or tinnitus D Lightheadedness or paresthesia

answer: d The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.

A female client with chronic obstructive pulmonary disease (COPD) takes aanhydrous theophylline, 200 mg P.O. every 8 hours. During a routine clinic visit, the client asks the nurse how the drug works. What is the mechanism of action of anhydrous theophylline in treating a nonreversible obstructive airway disease such as COPD? A It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive B It inhibits the enzyme phosphodiesterase, decreasing degradation of cyclic adenosine monophosphate, a bronchodilator C It stimulates adenosine receptors, causing bronchodilation D It alters diaphragm movement, increasing chest expansion and enhancing the lung's capacity for gas exchange

answer:a Anhydrous theophylline and other methylxanthine agents make the central respiratory center more sensitive to CO2 and stimulate the respiratory drive. Inhibition of phosphodiesterase is the drug's mechanism of action in treating asthma and other reversible obstructive airway diseases — not COPD. Methylxanthine agents inhibit rather than stimulate adenosine receptors. Although these agents reduce diaphragmatic fatigue in clients with chronic bronchitis or emphysema, they don't alter diaphragm movement to increase chest expansion and enhance gas exchange

A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is most at risk of developing which type of acid-base imbalance? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

Answer: 1 Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options 2, 3, and 4 are incorrect.

The nurse is preparing a client with pneumonia for discharge. Which statement by the client would alert the nurse to the fact that the client is in need of further discharge teaching? 1 "I will take all of my antibiotics, even if I do feel 100% better." 2 "You can toss out that incentive spirometer as soon as I leave for home." 3 "I realize that it may be weeks before my usual sense of well-being returns." 4 "It is a good idea for me to take a nap every afternoon for the next couple of weeks."

Answer: 2 Rationale: Deep breathing and coughing exercises and the use of incentive spirometry should be practiced for 6 to 8 weeks after the client with pneumonia is discharged from the hospital to keep the alveoli expanded and promote the removal of lung secretions. If the entire regimen of antibiotics is not taken, the client may suffer a relapse. Adequate rest is needed to maintain progress toward recovery. The period of convalescence with pneumonia is often lengthy, and it may be weeks before the client feels a sense of well-being.

The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client had respiratory acidosis? 1 pH 7.5, PCO2 of 30 2 pH 7.3, PCO2 of 50 3 pH 7.3, HCO3 of 19 4 pH 7.5, HCO3 of 30

Answer: 2 Rationale: In respiratory acidosis, the pH is decreased and an opposite effect is seen in the PCO2 (pH decreased, PCO2 elevated). Option 1 indicates respiratory alkalosis; option 3 indicates possible metabolic acidosis; and option 4 indicates possible metabolic alkalosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. Which acidbase disorder is most likely to occur in this client? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

Answer: 2 Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. Thus, the loss of hydrogen ions in the HCl results in alkalosis. Because the respiratory system is not involved, the alkalosis must be metabolic

The nurse reviews the client's most recent blood gas results that include a pH of 7.43, PCO2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid-base imbalance is present? 1 Compensated metabolic acidosis 2 Compensated respiratory alkalosis 3 Uncompensated respiratory acidosis 4 Uncompensated metabolic alkalosis

Answer: 2 Rationale: The normal pH is 7.35 to 7.45, the normal PCO2 is 35 to 45 mm Hg, and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, the pH and the PCO2 move in opposite directions; that is, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low also. In this client the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).

A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note which of the following types of breath sounds? 1 Absent 2 Vesicular 3 Bronchial 4 Bronchovesicular

Answer: 3 Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation, because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.

A nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening if which of the following occurs? 1 Loud wheezing 2 Wheezing on expiration 3 Noticeably diminished breath sounds 4 Wheezing during inspiration and expiration

Answer: 3 Rationale: Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on expiration. As the asthma attack progresses, the client may wheeze during both inspiration and expiration.

The nurse is assigned to care for a client with pneumonia. The nurse reviews the nursing care plan and notes documentation of a nursing diagnosis of Activity intolerance. The nurse implements which of the following in the client's care? 1 Encourages deep, rapid breathing during activity 2 Provides stimulation in the environment to maintain client alertness 3 Observes vital signs and oxygen saturation periodically during activity 4 Schedules activities before giving respiratory medications or treatments

Answer: 3 Rationale: The nurse monitors vital signs, including oxygen saturation, before, during, and after activity to gauge client response. Activities should be planned after giving the client respiratory medications or treatments to increase activity tolerance. The client should use pursed-lip and diaphragmatic breathing to lower oxygen consumption during activity. Finally, the environment should be conducive to rest because the client is easily fatigued.

The nurse is caring for a client diagnosed with pneumonia. The nurse plans which of the following as the best time to take the client for a short walk? 1 After the client eats lunch 2 After the client has a brief nap 3 After the client uses the metered-dose inhaler 4 After recording oxygen saturation on the bedside flow sheet

Answer: 3 Rationale: The nurse should schedule activities for the client with pneumonia after the client has received respiratory treatments or medications. After the administration of bronchodilators (often administered by metered-dose inhaler), the client has the best oxygen exchange possible and would tolerate the activity best. Still, the nurse implements activity cautiously, so as not to increase the client's dyspnea. The client would become fatigued after eating; therefore this is not a good time to ambulate the client. Although the client may be rested somewhat after a nap, from the options provided this is not the best time to ambulate. Option 4 is unrelated to the client's ability to tolerate ambulation

The nurse is caring for a client who just entered the emergency department. The client has a medical diagnosis of pneumonia and dehydration. Vital signs are blood pressure 76/42 mm Hg, heart rate 116 beats per minute, respirations of 22 breaths per minute with a pulse oximeter reading of 95% at room air and a temperature of 102.7_ F. The nurse should perform the following prescriptions in which priority order? (Number 1 is the first action and number 5 is the last action.) _____ Obtain blood and sputum cultures. _____ Administer 1 L of 0.9 normal saline. _____ Insert a large-bore needle intravenous catheter. _____ Administer acetaminophen (Tylenol) 650 mg orally. _____ Administer cefazolin (Ancef) 1 g intravenous piggyback (IIVPB).

Answer: 3, 2, 1, 4, 5 Rationale: The priority is to obtain intravenous access and give fluid resuscitation with the liter of 0.9 normal saline. The cultures are required next because they must be obtained before the administration of the antipyretic and antibiotic. The acetaminophen (Tylenol) is next because it is usually readily available via the medication administration system and will begin to take effect within 30 minutes. The antibiotic is then administered; it may take several hours to achieve an effect.

The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2 L per minute. The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse should take which initial action? 1. Determine the need to increase the oxygen. 2. Call emergency services to come to the home. 3. Reassure the client that there is no need to worry. 4. Collectmore information about the client's respiratory status.

Answer: 4 Test-Taking Strategy: Completing the assessment and collecting additional information regarding the client's respiratory status is the initial nursing action. The oxygen is not increased without validation of the need for further oxygen and the approval of the physician, especially because clients with COPD can retain carbon dioxide. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry. Use the steps of the nursing process to answer correctly and remember that assessment is the first step. Also, use the ABCs—airway, breathing, and circulation—to direct you to option 4. Remember to look for strategic words

After undergoing a thoracotomy, a male client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? A Heightened alertness B Increased heart rate C Numbness and tingling of the extremities D Respiratory depression

Respiratory depression is the most serious complication of epidural analgesia. Other potential complications include hypotension, decreased sensation and movement of the extremities, allergic reactions, and urine retention. Typically, epidural analgesia causes central nervous system depression (indicated by drowsiness) as well as a decreased heart rate and blood pressure.

A client with acute asthma is treated for inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which class of prescribed drugs should the nurse administer first to this client? 1. O ral steroids 2. Bronchodilators 3. I nhaled steroids 4. Mucolytics

answer 2. T he most immediate need of a client with inspiratory and expiratory wheezes and a decreased forced expiratory volume is to dilate the bronchioles and improve air exchange. Steroids (inhaled or oral) may follow the emergent treatment to reduce the inflammation, but would not be first-line drugs. Mucolytics are not appropriate for the client with asthma, as there is little mucus production associated with asthma.

. T he nurse is admitting a client who complains of fever, chills, chest pain, and dyspnea. The client has a heart rate of 110, respiratory rate of 28, and a nonproductive hacking cough. A chest x-ray confirms a diagnosis of left lower lobe pneumonia. Upon auscultation of the left lower lobe, the nurse documents which of the following breath sounds? 1. Bronchial 2. Bronchovesicular 3. Vesicular 4. A bsent breath sounds

answer 1 . I n the presence of pneumonia there will be bronchial breath sounds over the area of consolidation. The client may also have crackles in the affected side as a result of fluid in the interstitium and alveoli. Absence of breath sounds is not a usual finding and would not likely occur unless there was a serious complication

A client with asthma awakens in the middle of the night with an asthma attack. Which of the following inhaler medications should the nurse administer first? 1. Albuterol (Proventil) 2. T riamcinolone acetonide (Azmacort) 3. F luticasone propionate (Flovent) 4. C romolyn (Intal)

answer 1 . T he initial treatment for acute asthma is a bronchodilator. Steroids such as triamcinolone acetonide (Azmacort) and fluticasone propionate (Flovent) may be given after initial bronchospasm is relieved. Cromolyn (Intal) has no immediate effect and is a prophylactic mast cell inhibitor.

A client with pneumonia has a poor appetite, is dyspneic and complains of decreased taste sensation, and is receiving chest physiotherapy treatments and breathing treatments. Which of the following actions should the nurse include to improve the client's appetite? 1. P rovide mouth care before meals 2. P rovide juice and fluids at the bedside 3. P rovide three balanced meals each day 4. I ncrease fluid intake to 3 L a day

answer 1 because of the sputum production and expectoration, particularly during and after treatments, the client will have decreased taste sensation. Providing oral care after pulmonary treatments and before meals will improve taste and appetite. Fatigue from breathing, activity, and treatments will also decrease energy. Providing more frequent small meals (not three large ones), increasing fluid intake, and offering fluids that appeal to the client are appropriate interventions for the client but will not impact appetite.

A client with pneumonia has a poor appetite, is dyspneic and complains of decreased taste sensation, and is receiving chest physiotherapy treatments and breathing treatments. Which of the following actions should the nurse include to improve the client's appetite? 1. P rovide mouth care before meals 2. P rovide juice and fluids at the bedside 3. P rovide three balanced meals each day 4. I ncrease fluid intake to 3 L a day

answer 1. B ecause of the sputum production and expectoration, particularly during and after treatments, the client will have decreased taste sensation. Providing oral care after pulmonary treatments and before meals will improve taste and appetite. Fatigue from breathing, activity, and treatments will also decrease energy. Providing more frequent small meals (not three large ones), increasing fluid intake, and offering fluids that appeal to the client are appropriate interventions for the client but will not impact appetite.

A client with a history of asthma presents in the physician's office with complaints of difficulty breathing. While performing the initial assessment, the nurse becomes concerned that the client's respiratory status has worsened based on which of the following? 1. W heezing throughout the lung fields 2. N oticeably diminished breath sounds 3. L oud wheezing only on expiration 4. M ild wheezing on inspiration

answer 2 . T he severity of wheezing is not a reliable way to determine severity of an asthma attack. Some clients with minor attacks may have loud wheezing, whereas others may have severe attacks with mild wheezing. The client with severe asthma attacks may have no audible wheezing because of the decrease in airflow. For wheezing to occur, the client must be able to move air to produce sound. Wheezing usually occurs first on exhalation, and as the NURSINGasthma attack progresses, the client may wheeze during both inspiration and expiration. The significant finding with this assessment is that there are noticeably diminished breath sounds, which means reduced or absence of moving air. This may indicate severe obstruction and respiratory failure.

. A client with acute asthma is treated for inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which class of prescribed drugs should the nurse administer first to this client? 1. O ral steroids 2. Bronchodilators 3. I nhaled steroids 4. Mucolytics

answer 2 T he most immediate need of a client with inspiratory and expiratory wheezes and a decreased forced expiratory volume is to dilate the bronchioles and improve air exchange. Steroids (inhaled or oral) may follow the emergent treatment to reduce the inflammation, but would not be first-line drugs. Mucolytics are not appropriate for the client with asthma, as there is little mucus production associated with asthma

T he nurse is admitting a client who was recently diagnosed with asthma and has been taking a long-acting theophylline (Theo-Dur). After reviewing the client's history, the nurse discovered that the client has a manic disorder controlled by lithium (Eskalith). Which of the following is a priority for the nurse to include in this client's treatment plan? 1. I ncrease the dose of lithium 2. O btain a serum lithium level 3. I ncrease the dose of theophylline 4. O btain a consult for a psychiatric Consultation

answer 2 T heophylline may reduce the effects of lithium by increasing its rate of excretion. The client may need to have the dose of lithium increased, but not before the client's current serum lithium level is known. There is no indication to increase the theophylline dose. Obtaining a serum theophylline level would also be appropriate

A client who has asthma asks the nurse why the preferred route of administration for corticosteroids is inhalation. The appropriate response by the nurse is which of the following? 1. "Inhaled medications are easier to take." 2. "The systemic adverse reactions are reduced." 3. "No weaning is required when stopping the drug." 4. "Oral care is not required."

answer 2. T he inhaled glucocorticoids are effective on topical administration, and systemic adverse reactions can be reduced when delivered by this route. Instruction is necessary for the client to properly learn the technique of using inhalers. Inhaled steroids should not be stopped suddenly, and oral care is necessary after every treatment to reduce oral candidiasis.

client with a small bowel obstruction has had an NG tube connected to low intermittent suction for 2 days. The nurse should monitor for clinical manifestations of which acid-base disorder? 1. R espiratory alkalosis 2. R espiratory acidosis 3. M etabolic alkalosis 4. M etabolic acidosis

answer 3 Clients with gastric suctioning can lose hydrogen ions, resulting in a metabolic alkalosis. 3. C lients with gastric suctioning can lose hydrogen ions, resulting in a metabolic alkalosis.

T he nurse assesses a college-age client complaining of shortness of breath after jogging and tightness in his chest. Upon further questioning, the client denies a sore throat, fever, or productive cough. The nurse notifies the physician that this client's clinical manifestations are most likely related to 1. pneumonia. 2. bronchitis. 3. pneumoconiosis. 4. asthma.

answer 4 T he exercise may have induced bronchospasms. Lack of fever or productive cough would reduce the possibility of the clinical manifestations representing pneumonia or bronchitis. The occupation as a college student decreases the likelihood of an occupationally related lung disease

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? 1. C all the physician and report the change in client's condition 2. T urn the client's O2 up to 4 liters nasal cannula 3. E ncourage the client to sit down and to take deep breaths 4. E ncourage the client to rest and to use pursed-lip breathing technique

answer 4 4. C lients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since this client is presently most likely at baseline.

the nurse assesses a college-age client complaining of shortness of breath after jogging and tightness in his chest. Upon further questioning, the client denies a sore throat, fever, or productive cough. The nurse notifies the physician that this client's clinical manifestations are most likely related to 1. pneumonia. 2. bronchitis. 3. pneumoconiosis. 4. asthma.

answer 4. T he exercise may have induced bronchospasms. Lack of fever or productive cough would reduce the possibility of the clinical manifestations representing pneumonia or bronchitis. The occupation as a college student decreases the likelihood of an occupationally related lung disease

Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In a acute rhinitis, nasal drainage normally is: A Yellow B Green C Clear D Gray

answer: c Normally, nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection

A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which of the following is positive before the ABGs are drawn? 1 Allen test 2 Turner's sign 3 Babinski reflex 4 Brudzinski's sign

arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which of the following is positive before the ABGs are drawn? 1 Allen test 2 Turner's sign Answer: 1 Rationale: The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest

A nurse is caring for a client with an ileostomy understands that the client is at most risk for developing which acid base disorder? 1. resp acidosis 2. resp alkalosis 3. met acidosis 4. met alkalosis

answer: 3 Intestingal secretions are high in bicarbonate and may be lost through enteric draining tubes or an ileostomy or with diarrhea. These conditions result in metabolic alkalosis

36 A nURSE IS TEACHING A CLIENT WITH CHRONIC RESPIRATORY FAILURE HOW TO USE A METERED DOSE INHALER CORRECTLY. thE NURSE INSTRUCTS THE CLIENT TO 1. INHALE THROUGH THE NOSE 2. INHALE QUICKLY 3. TAKE 2 INHALATIONS DURING ONE BREATH 4. hold breath after inhalation

answer 4 old it right side up, inhale slowly and evenly through the mouth, deliver one spray per breath, and hold the breath after inhalation Instructions for using a meterd dose inhaler include to shake the canister, h

For a male client with an endotracheal (ET) tube, which nursing action is most essential? A Auscultating the lungs for bilateral breath sounds B Turning the client from side to side every 2 hours C Monitoring serial blood gas values every 4 hours D Providing frequent oral hygiene

answer: a For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.

Which phrase is used to describe the volume of air inspired and expired with a normal breath? A Total lung capacity B Forced vital capacity C Tidal volume D Residual volume

answer: c Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is the vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A Contralateral side in a simple pneumothorax B Affected side in a hemothorax C Affected side in a tension pneumothorax D Contralateral side in hemothorax

answer: d The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

1. T he nurse evaluates which of the following arterial blood gases for normal values? S elect all that apply: [ ] 1. pH of 7.30 [ ] 2. P aCO2 of 36 mm Hg [ ] 3. HCO 3- of 20 mEq/L [ ] 4. P aO2 of 84 mm Hg [ ] 5. P aCO2 of 30 mm Hg [ ] 6. pH of 7.43

2. 4. 6. Normal pH is 7.35. Normal PaCO2 is 35-45 mm Hg. Normal HCO3 is 22-26 mEq/l. Normal PaCO2 is 80-95 mm Hg. Normal O2 saturation is 95-99%. Arterial blood is slightly basic or alkaline with a pH of 7.35-7.45. Arterial blood pH rises above 7.45 if bicarbonate levels increase or hydrogen ions are lost. This condition is called alkalosis. Increased CO2 levels are present in acidosis. When decreased levels of CO2 are present, the respiratory center decreases the rate and depth of breaths to retain CO2 and increase hydrogen ion concentration.

When caring for a male patient who has just had a total laryngectomy, the nurse should plan to: A-Encourage oral feeding as soon as possible B-Develop an alternative communication method C-Keep the tracheostomy cuff fully inflated D-Keep the patient flat in bed

A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the patient in semi-fowler's position

A client with significant flail chest has arterial blood gases (ABGs) that reveal a PaO2 of 68 and a PaCO2 of 51. Two hours ago the PaO2 was 82 and the PaCO2 was 44. Based on these changes, the nurse obtains which of the following items? 1 Intubation tray 2 Chest tube insertion set 3 Portable chest x-ray machine 4 Injectable lidocaine (Xylocaine)

Answer: 1 Rationale: Flail chest occurs from a blunt trauma to the chest. The loose segment from the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall. The client with flail chest has painful, rapid, shallow respirations while experiencing severe dyspnea. The effort of breathing and the paradoxical chest movement have the net effect of producing hypoxia and hypercapnia. The client develops respiratory failure and requires intubation and mechanical ventilation, usually with positive end expiratory pressure (PEEP); therefore an intubation tray is necessary.