Nokea
A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?
- A. Intubation and mechanical ventilation
- B. Face mask with nonrebreather
- C. Oxygen cannula at 6 L/minute
- D. Venturi mask at 35%
Correct Answer: A
Rationale: The client's respiratory status is severely compromised and has developed signs of respiratory failure. When respiratory failure occurs, the client is intubated and oxygen is administered under continuous positive airway pressure or with mechanical ventilation with positive end-expiratory pressure. A face mask, cannula, or Venturi mask will not deliver the concentration or ventilatory support that an endotracheal tube with mechanical ventilation will provide.
You may also like to solve these questions
The nurse is caring for a client in the hospital with chronic heart failure that has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?
- A. Class I (Mild)
- B. Class II (Mild)
- C. Class III (Moderate)
- D. Class IV (Severe)
Correct Answer: C
Rationale: Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.
A client with heart failure reports not having had a bowel movement in 2 days. Why would it be important for the nurse to obtain a prescription for a stool softener?
- A. Straining engages the Valsalva maneuver, which can cause dangerous effects.
- B. The client should not develop hemorrhoids.
- C. The client can develop a rectal fissure, which will increase pain levels.
- D. The client should have a bowel movement every day to avoid development of an intestinal obstruction.
Correct Answer: A
Rationale: Avoid activities that engage the Valsalva maneuver, such as straining with bowel elimination or using the arms to pull and reposition oneself. The Valsalva maneuver increases intrathoracic pressure, reduces right atrial filling, triggers tachycardia, and increases blood pressure. The client's discomfort would be increased if hemorrhoids or a rectal fissure developed but would not engage the Valsalva maneuver. It is not necessary for the client to have a bowel movement on a daily basis.
A client is admitted to the hospital with a diagnosis of heart failure, and the health care provider prescribes a BNP level. What results would indicate to the nurse that the client is in moderate heart failure?
- A. 120 pg/mL
- B. 400 pg/mL
- C. 780 pg/mL
- D. 980 pg/mL
Correct Answer: C
Rationale: The result of 780 pg/mL indicates that the client has moderate heart failure, 120 pg/mL indicates that the client has heart failure present, 400 pg/mL indicates that the client has mild heart failure, and 980 pg/mL indicates that the client is in severe heart failure.
A client with chronic heart failure is able to continue with his regular physical activity and does not have any limitations as to what he can do. According to the New York Heart Association (NYHA), what classification of chronic heart failure does this client have?
- A. Class I (Mild)
- B. Class II (Mild)
- C. Class III (Moderate)
- D. Class IV (Severe)
Correct Answer: A
Rationale: Class I is when ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
- A. Administer the medication and inform the charge nurse about the rate.
- B. Withhold the medication and notify the health care provider of the heart rate.
- C. Administer atropine to speed the heart rate and then administer the digoxin.
- D. Administer the medications and then notify the health care provider.
Correct Answer: B
Rationale: Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a health care provider is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.