RN OXYGENATION/GAS II
Fat embolism syndrome
is characterized by fever tachycardia tachypnea hypoxia Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg with early respiratory alkalosis and later respiratory acidosis.
increased residual volume and a decreased vital capacity- best nursing diagnosis Risk for activity intolerance Explanation: These findings indicate respiratory disease; this client will have shortness of breath with exertion because of the trapped air. The client may have impaired physical mobility because of the inability to tolerate activities. Altered health maintenance or risk for fluid volume deficit are not supported by the test results.
A client's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis? Risk for activity intolerance Explanation: These findings indicate respiratory disease; this client will have shortness of breath with exertion because of the trapped air. The client may have impaired physical mobility because of the inability to tolerate activities. Altered health maintenance or risk for fluid volume deficit are not supported by the test results.
tetralogy of Fallot (TOF) Knee-to-chest Explanation: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.
A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? Knee-to-chest Explanation: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.
cystic fibrosis (CF)- PSYCHO-SOCIAL It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff. Explanation: A client who has endured serious chronic illness (both psychiatric and medical) would be well aware of his shortened lifespan, particularly if he is unable to get a lung transplant. It would not be unusual for him to want to plan ahead so his wishes would be honored in the event of his death. In the absence of other physical signs, an exacerbation of CF or delirium is not demonstrated. Likewise, his successful bipolar treatment in the absence of any other signs rules depression out as a reason for his behavior. Though it may be difficult to think about a young person in terms of dying, the client's consideration of the future is a rational decision.
A 19-year-old male with cystic fibrosis (CF) is hospitalized for a serious lung infection and is in need of a lung transplant. However, he has a rare blood type that complicates the process of obtaining a donor organ. He has also been diagnosed with bipolar disorder and treated successfully since mid-adolescence with medication and therapy. The client requests to see a chaplain to help him make plans for a funeral and donation of his body to science after death. How should the nurse interpret the client's request? Correct response: It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff. Explanation: A client who has endured serious chronic illness (both psychiatric and medical) would be well aware of his shortened lifespan, particularly if he is unable to get a lung transplant. It would not be unusual for him to want to plan ahead so his wishes would be honored in the event of his death. In the absence of other physical signs, an exacerbation of CF or delirium is not demonstrated. Likewise, his successful bipolar treatment in the absence of any other signs rules depression out as a reason for his behavior. Though it may be difficult to think about a young person in terms of dying, the client's consideration of the future is a rational decision.
severe asthma attack albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.
A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first? albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.
acute bacterial pneumonia - The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Correct Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Correct Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.
Auscultation of the left lower lung reveals vesicular breath sounds Further assess the client for reinflation of the lung. Explanation: A lack of bubbling in the water chamber and normal lung sounds are an indication that lung reinflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the physician for possible removal of the chest tube
A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse? Further assess the client for reinflation of the lung. Explanation: A lack of bubbling in the water chamber and normal lung sounds are an indication that lung reinflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the physician for possible removal of the chest tube
TURP- transurethral resection of the prostate-anesthesia respiratory paralysis. Explanation: If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.
A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should assess the client for: respiratory paralysis. Explanation: If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.
carbon monoxide poisoning- clinical manifestations Dizziness • Pulse oximetry of 99% on room air • Headache • Nausea and vomiting Explanation: One of the first signs of carbon monoxide poisoning is a headache. Dizziness and nausea/vomiting may also occur. A client with carbon monoxide poisoning is likely to present with a high pulse oximetry reading. The nurse should understand that pulse oximetry measures saturation of red blood cells. It is unable to distinguish between saturation with oxygen and saturation with carbon monoxide. This client will likely present with a high pulse oximetry reading, but his or her red blood cells are saturated with carbon monoxide and not oxygen. Chills are not an expected finding.
A client with carbon monoxide poisoning is treated in the emergency department of an acute care facility. Which of the following clinical manifestations should the nurse expect in this client? Select all that apply. • Dizziness • Pulse oximetry of 99% on room air • Headache • Nausea and vomiting Explanation: One of the first signs of carbon monoxide poisoning is a headache. Dizziness and nausea/vomiting may also occur. A client with carbon monoxide poisoning is likely to present with a high pulse oximetry reading. The nurse should understand that pulse oximetry measures saturation of red blood cells. It is unable to distinguish between saturation with oxygen and saturation with carbon monoxide. This client will likely present with a high pulse oximetry reading, but his or her red blood cells are saturated with carbon monoxide and not oxygen. Chills are not an expected finding.
THROMBOLYTIC AGENT MUST BE ADMINISTERED WITHIN 6HRS AFTER THE ONSET OF MI Within 6 hours Explanation: For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.
A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms? Within 6 hours Explanation: For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.
seizure Maintain a patent airway. Explanation: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure. Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure. Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.
A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately? Maintain a patent airway. Explanation: The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia. Because the client is diagnosed with eclampsia, she is at risk for seizures. Thus, seizure precautions, including padding the side rails, should have been instituted prior to the seizure. Placing a pillow under the client's left buttock would be of little help during a tonic-clonic seizure. Inserting a padded tongue blade is not recommended because injury to the client or nurse may occur during insertion attempts.
HF- left-sided heart failure- increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum acute pulmonary edema. Correct Explanation: Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of: acute pulmonary edema. Explanation: Shortness of breath, agitation, and pink-tinged, foamy sputum signal acute pulmonary edema. This condition results when decreased contractility and increased fluid volume and pressure in clients with heart failure drive fluid from the pulmonary capillary beds into the alveoli. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock is indicated by signs of hypotension and tachycardia.
The client becomes restless and dyspneic and has chest pain radiating to the middle of the back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. a pneumothorax. Explanation: The client is exhibiting signs and symptoms of a pneumothorax from the insertion of the subclavian venous catheter. Although it is possible that the client suffered an air embolus during the procedure, and the client is at risk for pulmonary emboli because of his immobility, absent breath sounds immediately after insertion of a subclavian line are strongly suggestive of a pneumothorax. Unilateral absent breath sounds are not associated with a myocardial infarction.
A client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes restless and dyspneic and has chest pain radiating to the middle of the back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for: You selected: a pulmonary embolus. Incorrect Correct response: a pneumothorax. Explanation: The client is exhibiting signs and symptoms of a pneumothorax from the insertion of the subclavian venous catheter. Although it is possible that the client suffered an air embolus during the procedure, and the client is at risk for pulmonary emboli because of his immobility, absent breath sounds immediately after insertion of a subclavian line are strongly suggestive of a pneumothorax. Unilateral absent breath sounds are not associated with a myocardial infarction.
tuberculosis- DROPLET PRECAUTIONS Wearing a mask when caring for the client Explanation: Nurses should wear a mask when caring for clients with tuberculosis, and should enter the client's room more than every 2 hours. Dietary personnel should not enter this client's room, and an isolation gown is not necessary.
A nurse is caring for a client with tuberculosis. Which infection control technique is necessary when caring for this client? Wearing a mask when caring for the client Explanation: Nurses should wear a mask when caring for clients with tuberculosis, and should enter the client's room more than every 2 hours. Dietary personnel should not enter this client's room, and an isolation gown is not necessary.
endotracheal intubation An uncuffed endotracheal tube Explanation: An uncuffed endotracheal tube is used because the cricoid cartilage in the toddler is the narrowest part of the larynx and provides a natural seal. This aspect keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. Although the trachea is shorter and the larynx is anterior and cephalad, these aren't reasons to choose an uncuffed tube.
A nurse is caring for a toddler in respiratory distress requiring endotracheal intubation. When gathering supplies, which item should the nurse obtain that is most important for this child? An uncuffed endotracheal tube Explanation: An uncuffed endotracheal tube is used because the cricoid cartilage in the toddler is the narrowest part of the larynx and provides a natural seal. This aspect keeps the endotracheal tube in place without requiring a cuff. The vocal cords are narrower in an adult. Although the trachea is shorter and the larynx is anterior and cephalad, these aren't reasons to choose an uncuffed tube.
fractured pelvis Fat embolism Explanation: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.
After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? Fat embolism Explanation: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.
theophylline- effectiveness of this medication less difficulty breathing Explanation: Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions
The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, the nurse should assess the client for: less difficulty breathing Explanation: Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions
hemopneumothorax A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Explanation: Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax; splinting of the ribs will not resolve the hemopneumothorax. Oxygen would be indicated, but a bronchoscopy will not confirm the area of damage if the lung is collapsed.
The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Explanation: Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax; splinting of the ribs will not resolve the hemopneumothorax. Oxygen would be indicated, but a bronchoscopy will not confirm the area of damage if the lung is collapsed.
bronchoscopy • Ask the client to remove any dentures. • Confirm that a signed informed consent form has been obtained. • Administer atropine and a sedative. • Explain the procedure. Explanation: All procedures must be explained to the client to obtain informed consent and reduce anxiety. A signed informed consent form is required for all invasive procedures. Dentures need to be removed for bronchoscopy, because they may become dislodged during the procedure. Atropine is administered before bronchoscopy to decrease secretions. A sedative may be given to relax the client. Food and fluids are restricted for 6 to 12 hours before the test to avoid the risk of aspiration during the procedure.
The nurse is caring for a client scheduled for a bronchoscopy. Which interventions should the nurse perform to prepare the client for this procedure? Select all that apply. • Ask the client to remove any dentures. • Confirm that a signed informed consent form has been obtained. • Administer atropine and a sedative. • Explain the procedure. Explanation: All procedures must be explained to the client to obtain informed consent and reduce anxiety. A signed informed consent form is required for all invasive procedures. Dentures need to be removed for bronchoscopy, because they may become dislodged during the procedure. Atropine is administered before bronchoscopy to decrease secretions. A sedative may be given to relax the client. Food and fluids are restricted for 6 to 12 hours before the test to avoid the risk of aspiration during the procedure.
tracheostomy tube make sure the gauze pad is dry and the client is in a comfortable position. Explanation: The tracheostomy tube, ties, and gauze pad are positioned correctly; the nurse team leader should be sure the client is comfortable. The tracheostomy tube ties should be tied in a square knot on the side of the neck and alternate sides of the neck when the ties are changed. The full part of the gauze square should be placed under the tracheostomy tube to absorb drainage. There is no indication the ties need to be changed; an additional gauze pad is not necessary; if necessary, the current gauze square should be changed rather than add an additional pad.
The nurse is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (see figure). The nursing policy manual recommends use of the gauze pad. The nurse should: make sure the gauze pad is dry and the client is in a comfortable position. Explanation: The tracheostomy tube, ties, and gauze pad are positioned correctly; the nurse team leader should be sure the client is comfortable. The tracheostomy tube ties should be tied in a square knot on the side of the neck and alternate sides of the neck when the ties are changed. The full part of the gauze square should be placed under the tracheostomy tube to absorb drainage. There is no indication the ties need to be changed; an additional gauze pad is not necessary; if necessary, the current gauze square should be changed rather than add an additional pad.
asthma Hello. My name is Nurse Jones from Unit D. I am notifying you because Bob Smith has become increasingly more short of breath with audible wheezing this afternoon. Mr. Smith was admitted yesterday with an exacerbation of Asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Explanation: SBAR communication stands for Situation, Background, Assessment, and Recommendation. First, the nurse must identify his/herself and where he /she is calling from. Next, the nurse would begin explaining the client situation (change in condition). The nurse would provide background information such as diagnosis, admission status and date. The nurse would provide a focused assessment on the area of concern. Lastly, the nurse would offer a recommendation for client care.
The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used. Hello. My name is Nurse Jones from Unit D. I am notifying you because Bob Smith has become increasingly more short of breath with audible wheezing this afternoon. Mr. Smith was admitted yesterday with an exacerbation of Asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Explanation: SBAR communication stands for Situation, Background, Assessment, and Recommendation. First, the nurse must identify his/herself and where he /she is calling from. Next, the nurse would begin explaining the client situation (change in condition). The nurse would provide background information such as diagnosis, admission status and date. The nurse would provide a focused assessment on the area of concern. Lastly, the nurse would offer a recommendation for client care.
coronary artery disease Enhance myocardial oxygenation Explanation: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration is not the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.
The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be which of the following? Enhance myocardial oxygenation Explanation: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration is not the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.
myasthenia gravis maintain respiratory function. Explanation: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment and emotional support are secondary goals. Pain is not commonly associated as a problem of myasthenia gravis.
The primary nursing goal for a client with myasthenia gravis is to: maintain respiratory function. Explanation: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment and emotional support are secondary goals. Pain is not commonly associated as a problem of myasthenia gravis.
postictal phase of a seizure Assess the client's breathing pattern. Explanation: A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.
What is the priority nursing intervention in the postictal phase of a seizure? Assess the client's breathing pattern. Explanation: A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.
Guillain-Barré syndrome Preparing for mechanical ventilation Explanation: As this disease progresses, the nurse can expect the client to have weakness and possible paralysis of the diaphragm. This may lead to respiratory failure and require mechanical ventilation. This is the primary concern for the client. The other issues are not as high a priority as maintaining a patent airway
Which of the following nursing actions addresses the primary concern for a client with Guillain-Barré syndrome? Preparing for mechanical ventilation Explanation: As this disease progresses, the nurse can expect the client to have weakness and possible paralysis of the diaphragm. This may lead to respiratory failure and require mechanical ventilation. This is the primary concern for the client. The other issues are not as high a priority as maintaining a patent airway
emphysema 80 mm Hg Explanation: Although normal PaCO2 values range from 35 to 45 mm Hg, the client with long-standing emphysema has chronic carbon dioxide retention, leading to elevated PaCO2 levels. A PaCO2 level of 80 mm Hg is life threatening and always requires immediate intervention, possibly mechanical ventilation, to reduce the PaCO2 level. The client with emphysema and a PaCO2 level of 60 mm Hg may not be in immediate danger, but the nurse should further evaluate the client with this level.
While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which PaCO2 values as indicating the need for immediate intervention? You selected: 80 mm Hg Explanation: Although normal PaCO2 values range from 35 to 45 mm Hg, the client with long-standing emphysema has chronic carbon dioxide retention, leading to elevated PaCO2 levels. A PaCO2 level of 80 mm Hg is life threatening and always requires immediate intervention, possibly mechanical ventilation, to reduce the PaCO2 level. The client with emphysema and a PaCO2 level of 60 mm Hg may not be in immediate danger, but the nurse should further evaluate the client with this level.