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A healthcare professional is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, and HCO3 22 mm Hg. The healthcare professional should recognize that the client is experiencing which of the following acid-base imbalances?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: The ABG results show a high pH (alkalosis) along with low PaCO2 and normal HCO3 levels, indicating respiratory alkalosis. In this condition, there is excessive loss of carbon dioxide (as seen by the low PaCO2) leading to a decrease in carbonic acid concentration and subsequent increase in pH. Metabolic acidosis or alkalosis would involve primary changes in bicarbonate levels, which are not predominant in this case.
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A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?
- A. Non-rebreather mask
- B. Venturi mask
- C. Nasal cannula
- D. Simple face mask
Correct Answer: B
Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.
During the removal of a chest tube, what should the nurse instruct the client to do?
- A. Lie on their left side.
- B. Use the incentive spirometer.
- C. Cough at regular intervals.
- D. Perform the Valsalva maneuver.
Correct Answer: D
Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.
A client is being educated by a healthcare provider on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?
- A. ''This medication can decrease my immune response.''
- B. ''I take this medication to prevent asthma attacks.''
- C. ''I need to take this medication with food.''
- D. ''This medication has a slow onset to treat my symptoms.''
Correct Answer: B
Rationale: The correct answer is, 'I take this medication to prevent asthma attacks.' Bronchodilators are commonly used to relieve bronchospasm in conditions such as asthma. This medication helps to dilate the airways, making it easier to breathe and preventing asthma attacks. The other options are incorrect: option A is inaccurate as bronchodilators do not decrease immune responses, option C is incorrect as bronchodilators are typically taken on an empty stomach for better absorption, and option D is false as bronchodilators have a rapid onset to provide quick relief of symptoms.
When preparing an in-service on malpractice issues in nursing, which of the following examples should the nurse include in the teaching?
- A. Leaving a nasogastric tube clamped after administering oral medication
- B. Documenting communication with a provider in the progress notes of the client's medical record
- C. Administering potassium via IV bolus
- D. Placing a yellow bracelet on a client who is at risk for falls
Correct Answer: C
Rationale: Administering potassium via IV bolus is a high-risk procedure that requires careful attention and adherence to established protocols to prevent serious complications like cardiac arrest. Errors in administering IV medications, especially potent ones like potassium, can lead to severe harm to the patient and potential legal consequences for the healthcare provider. Therefore, including this example in the in-service on malpractice issues helps emphasize the importance of safe medication administration practices and the potential implications of errors.
A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
- A. Apply a vest restraint if self-extubation is attempted.
- B. Monitor ventilator settings every 8 hours.
- C. Document tube placement in centimeters at the angle of the jaw.
- D. Assess breath sounds every 1 to 2 hours.
Correct Answer: D
Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.