Nokea
A client with chronic obstructive pulmonary disease (COPD) presented with shortness of breath. Oxygen therapy was started at 2 liters/minute via nasal cannula. The arterial blood gases (ABGs) after treatment were pH 7.36, PaO2 52, PaCO2 59, HCO3 33. Which statement describes the most likely cause of the simultaneous increase in both PaO2 and PaCO2?
- A. The client is hyperventilating due to anxiety.
- B. The hypoxic drive was reduced by the oxygen therapy.
- C. The client is experiencing respiratory alkalosis.
- D. The client is experiencing metabolic acidosis.
Correct Answer: B
Rationale: Oxygen therapy can reduce the hypoxic drive in COPD patients, leading to increased PaCO2 levels while improving oxygenation (PaO2). In this case, the increase in PaO2 and PaCO2 is due to the reduction of the hypoxic drive by the supplemental oxygen. Choice A is incorrect because hyperventilation would lead to decreased PaCO2. Choice C is incorrect as the ABG values do not indicate respiratory alkalosis. Choice D is incorrect as the ABG values do not support metabolic acidosis.
You may also like to solve these questions
Which finding should the nurse report immediately for a client receiving a blood transfusion?
- A. Mild itching and rash
- B. Temperature increase of 1.5°F (0.8°C)
- C. Heart rate increase of 10 beats per minute
- D. Slight headache
Correct Answer: B
Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes an NG tube to be inserted and placed on intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
- A. Soak the NG tube in warm water
- B. Insert the tube with the client's head tilted back
- C. Apply suction while inserting the tube
- D. Elevate the head of the bed 60 to 90 degrees
Correct Answer: D
Rationale: Elevating the head of the bed 60 to 90 degrees is the correct intervention to facilitate proper placement of the NG tube. This position helps to use gravity to guide the tube smoothly into the gastrointestinal tract. Soaking the NG tube in warm water (Choice A) is not necessary for proper placement. Inserting the tube with the client's head tilted back (Choice B) can cause discomfort and may lead to improper placement. Applying suction while inserting the tube (Choice C) is not recommended as it can cause trauma to the nasal passages and esophagus.
What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?
- A. Assist with referral to specialized education.
- B. Support the child with independent toileting.
- C. Assist the child to develop effective communication.
- D. Encourage the child to ambulate independently.
Correct Answer: C
Rationale: The correct answer is C: 'Assist the child to develop effective communication.' Children with cerebral palsy often face challenges with communication skills. Therefore, priority nursing interventions aim to help them improve their communication abilities. Choice A is incorrect because while education is important, the priority for a child with cerebral palsy is to address immediate needs. Choice B is incorrect as toileting, although important, is not the priority in this case. Choice D is incorrect as ambulation may not be feasible or the most critical concern for a child with cerebral palsy.
The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?
- A. Pain rated 7/10 on the pain scale.
- B. Mild swelling at the fracture site.
- C. Small amount of bleeding from the surgical site.
- D. Left extremity capillary refill greater than 5 seconds.
Correct Answer: D
Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.
The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)
- A. Abdominal obesity
- B. Blood pressure of 150/96 mmHg
- C. Increased triglyceride levels
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, as all the listed factors - abdominal obesity, high blood pressure, and increased triglyceride levels - are components of metabolic syndrome. Addressing these findings is crucial to help reduce the client's risk for developing diabetes mellitus and vascular disease. Abdominal obesity is a key feature of metabolic syndrome, high blood pressure (150/96 mmHg) is a risk factor, and increased triglyceride levels are also indicative of the syndrome. Educating the client on lifestyle modifications, such as healthy eating habits, regular physical activity, and monitoring these parameters, is essential in managing metabolic syndrome and preventing associated complications. Choices A, B, and C are all correct, making choice D the correct answer.