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A nurse is caring for a client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?
- A. Decreased respiratory rate.
- B. Pallor.
- C. Low arterial PaO2.
- D. An elevated arterial PaO2.
Correct Answer: C
Rationale: The correct answer is C: Low arterial PaO2. In acute respiratory distress syndrome (ARDS), there is impaired gas exchange leading to hypoxemia. Low arterial PaO2 indicates poor oxygenation in the blood, a hallmark of ARDS. Decreased respiratory rate (A) is unlikely as the body compensates by increasing respiratory effort. Pallor (B) is a general sign of reduced blood flow and not specific to ARDS. An elevated arterial PaO2 (D) would not be expected in ARDS, as it signifies adequate oxygenation.
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After change of shift, you are assigned to care for the following clients. Which client should you assess first?
- A. A 68-year-old client on ventilator who needs a sterile sputum specimen sent to the laboratory
- B. A 57-year-old client with COPD and pulse oximetry reading from previous shift of 90% saturation
- C. A 72-year-old client with pneumonia who needs to be started on intravenous antibiotics
- D. A 51-year-old client with asthma complaining of shortness of breath (SOB) after using a bronchodilator inhaler
Correct Answer: D
Rationale: The correct answer is D. A client with acute SOB after using a bronchodilator requires immediate attention. Clients on ventilators (A), with stable but low oxygen saturation (B), or needing antibiotics (C) are important but less urgent.
The nurse has assessed a patient's family history for three generations. The presence of
which respiratory disease would justify this type of assessment?
- A. Asthma
- B. Obstructive sleep apnea
- C. Community-acquired pneumonia
- D. Pulmonary edema
Correct Answer: A
Rationale: Step-by-step rationale:
1. Asthma is a hereditary respiratory disease, making it important to assess family history.
2. Genetic predisposition plays a role in the development of asthma.
3. Understanding family history helps in identifying potential risk factors.
4. Obstructive sleep apnea, community-acquired pneumonia, and pulmonary edema are not typically hereditary respiratory diseases.
5. Therefore, assessing family history for three generations is justified for asthma.
A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next?
- A. Assess the client for obstructive sleep apnea.
- B. Arrange a home sleep apnea test.
- C. Encourage the client to begin exercising.
- D. Schedule a polysomnography
Correct Answer: A
Rationale: The correct answer is A: Assess the client for obstructive sleep apnea. Hypertension that is not responding to medications may be due to underlying sleep apnea, a common comorbidity. By assessing for obstructive sleep apnea, the nurse can identify a potential contributing factor to the client's uncontrolled hypertension. This step is crucial in managing the client's condition effectively.
Summary of other choices:
B: Arranging a home sleep apnea test may be premature without first assessing the client for obstructive sleep apnea.
C: Encouraging the client to begin exercising is important for overall health but may not directly address the uncontrolled hypertension.
D: Scheduling a polysomnography may be necessary if obstructive sleep apnea is suspected after the initial assessment.
A 62-yr-old client who has no history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP.What is most appropriate for the nurse to tell the client
- A. BP recheck should be scheduled in a few weeks.
- B. dietary sodium and fat content should be decreased.
- C. diagnosis, treatment, and monitoring will be needed.
- D. there is danger of a stroke, requiring hospitalization.
Correct Answer: C
Rationale: The correct answer is C because a sudden spike in blood pressure to 198/110 mm Hg is considered hypertensive crisis requiring immediate medical attention. The nurse should inform the client that diagnosis, treatment, and monitoring are necessary to address the high blood pressure. This is important to prevent serious complications like stroke or heart attack.
Option A is incorrect because waiting a few weeks for a BP recheck could be dangerous in this scenario. Option B is also incorrect as simple dietary changes may not be sufficient to address such high blood pressure levels. Option D is incorrect as hospitalization may or may not be required based on the assessment and treatment plan determined by the healthcare provider.
Stimulation of the apneustic center would result in
- A. increased respiratory rate
- B. more intense inhalation
- C. a shorter respiratory cycle
- D. less activity in the DRG center
Correct Answer: B
Rationale: The correct answer is B: more intense inhalation. The apneustic center is responsible for prolonging inhalation by stimulating the inspiratory neurons in the medulla oblongata. When the apneustic center is stimulated, it disrupts the normal breathing pattern, causing a prolonged and more intense inhalation. This results in deeper and more forceful breaths.
Incorrect choices:
A: increased respiratory rate - Stimulation of the apneustic center would not lead to an increased respiratory rate, but rather to changes in the depth and intensity of inhalation.
C: a shorter respiratory cycle - The apneustic center's stimulation does not lead to a shorter respiratory cycle, but rather to a prolonged inhalation phase.
D: less activity in the DRG center - The dorsal respiratory group (DRG) is responsible for initiating inspiration, and the apneustic center does not affect its activity.