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A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?
- A. Pallor
- B. Low arterial PaO2
- C. Elevated arterial PaO2
- D. Decreased respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Low arterial PaO2. In acute respiratory distress syndrome (ARDS), there is inadequate oxygen exchange in the lungs, leading to low PaO2 levels. This is due to alveolar damage and decreased lung compliance. Pallor (choice A) is not a specific finding in ARDS. Elevated arterial PaO2 (choice C) is not expected in ARDS as it indicates sufficient oxygenation. Decreased respiratory rate (choice D) is not a typical finding in ARDS, as patients often have an increased respiratory rate to compensate for the poor oxygenation.
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Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest?
- A. Severe hypotension
- B. Chest pain over ribs
- C. Absence of breath sounds
- D. Paradoxical chest movement
Correct Answer: D
Rationale: Flail chest is characterized by paradoxical chest movement, where a segment of the chest wall moves in the opposite direction during breathing. This can lead to respiratory compromise and requires careful monitoring and management.
In general, when looking at acid-base balance, how does the body compensate with metabolic acidosis?
- A. Lungs ""blow off"" CO2 to raise pH
- B. Lungs retain CO2 to lower pH
- C. Kidneys retain more HCO3 to raise the pH
- D. Kidneys excrete more HCO3 to lower pH
Correct Answer: A
Rationale: The correct answer is A. In metabolic acidosis, the lungs compensate by increasing respiratory rate and depth ('blowing off' CO2) to reduce acidity and raise pH. B is incorrect because retaining CO2 would worsen acidosis. C is partially true long-term but slower acting than pulmonary compensation. D is incorrect because excreting bicarbonate lowers pH further.
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patient's blood?
- A. A capillary blood sample
- B. Pulse oximetry
- C. An arterial blood gas (ABG) study
- D. A complete blood count (CBC)
Correct Answer: C
Rationale: The correct answer is C: An arterial blood gas (ABG) study. This is the most accurate measurement of the concentration of oxygen in the patient's blood because ABG provides direct measurement of oxygen levels, including partial pressure of oxygen (PaO2). It also gives information on other important parameters like pH and carbon dioxide levels. Arterial blood is the best representation of oxygenation status.
Choice A (A capillary blood sample) may provide some information on oxygen saturation but is not as accurate as an ABG for measuring oxygen levels in the blood.
Choice B (Pulse oximetry) measures oxygen saturation in peripheral blood and can give a quick estimate of oxygen levels, but it is not as accurate as an ABG for determining the actual oxygen concentration in the blood.
Choice D (A complete blood count) does not provide direct information on oxygen levels in the blood, as it mainly focuses on the cellular components of blood such as red blood cells, white blood cells, and
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the client's decrease in self-esteem are being met?
- A. The client demonstrates good understanding of stoma care.
- B. The client has joined a book club that meets at the library.
- C. Family members take turns assisting with stoma care.
- D. Skin around the stoma is intact without signs of infection.
Correct Answer: B
Rationale: The correct answer is B because joining a book club shows an improvement in social engagement and participation, indicating an increase in self-esteem. This choice demonstrates the client's interest in activities outside of their healthcare needs, promoting a sense of normalcy and connection. In contrast, options A, C, and D focus solely on stoma care and physical aspects, not directly related to self-esteem. Understanding stoma care (A) is important but does not address self-esteem directly. Family assistance (C) is supportive but does not necessarily indicate an improvement in the client's self-esteem. Skin integrity (D) is essential for physical health but does not reflect self-esteem.
During inspiration
- A. diaphragm relaxes and thoracic space decrease
- B. diaphragm contract only
- C. Diaphragm contract and thoracic space increase
- D. both A and D
Correct Answer: C
Rationale: During inspiration, the diaphragm contracts, causing it to move downward and increase the thoracic space. This creates a negative pressure in the lungs, allowing air to rush in. Choice A is incorrect as the diaphragm contracts rather than relaxes during inspiration. Choice B is incorrect since other muscles like the external intercostals also aid in expanding the thoracic cavity. Choice D is incorrect because it combines a correct statement with an incorrect one. Therefore, the correct answer is C as it accurately describes the process of inspiration involving both diaphragm contraction and an increase in thoracic space.