Nokea
A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry indicates that the O2 saturation is 94%. Which action should the nurse take next?
- A. Administer bicarbonate.
- B. Complete a head-to-toe assessment.
- C. Place the patient on high-flow oxygen.
- D. Obtain repeat arterial blood gases (ABGs).
Correct Answer: C
Rationale: In a patient with metabolic alkalosis and an O2 saturation of 94%, placing the patient on high-flow oxygen is the correct action. Even though the O2 saturation seems adequate, metabolic alkalosis causes a left shift in the oxyhemoglobin dissociation curve, reducing oxygen delivery to tissues. Therefore, providing high-flow oxygen can help compensate for this. Administering bicarbonate would exacerbate the alkalosis. While completing a head-to-toe assessment and obtaining repeat ABGs are important interventions, the priority in this scenario is to improve oxygen delivery by placing the patient on high-flow oxygen.
You may also like to solve these questions
Which of the following conditions is a contraindication for performing a diagnostic peritoneal lavage?
- A. A client who is 9 weeks pregnant
- B. A client with a femur fracture
- C. A morbidly obese client
- D. A client with hypertension
Correct Answer: C
Rationale: Diagnostic peritoneal lavage is contraindicated in morbidly obese clients due to several reasons. Excess body fat in morbidly obese individuals makes it challenging to locate essential landmarks required for the procedure. Additionally, the equipment utilized for the lavage may not be sized appropriately to accommodate an obese individual. Furthermore, morbid obesity places undue stress on the cardiovascular and respiratory systems, increasing the risk of complications when administering anesthetic agents during the procedure. Therefore, performing a diagnostic peritoneal lavage on a morbidly obese client is not recommended.
Choice A, a client who is 9 weeks pregnant, is not a contraindication for diagnostic peritoneal lavage. Pregnancy status alone does not preclude the procedure unless there are specific maternal or fetal concerns.
Choice B, a client with a femur fracture, is not a contraindication for diagnostic peritoneal lavage. The presence of a femur fracture does not typically affect the ability to perform this diagnostic procedure.
Choice D, a client with hypertension, is not a contraindication for diagnostic peritoneal lavage. Hypertension, while a consideration for anesthesia and surgery, does not directly impact the feasibility of performing a diagnostic peritoneal lavage.
A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?
- A. Do not let this prescription run out.
- B. The medication may cause gingival hyperplasia.
- C. Periodic serum drug levels are needed.
- D. Watch for excessive facial hair growth.
Correct Answer: A
Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct Answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
- A. Start a peripheral IV line to administer any necessary sedative drugs.
- B. Position the patient sitting upright on the edge of the bed and leaning forward.
- C. Obtain a collection device to hold a reasonable amount of pleural fluid for extraction.
- D. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
Correct Answer: B
Rationale: The correct action for the nurse to take in preparing a patient for a thoracentesis is to position the patient sitting upright on the edge of the bed and leaning forward. This position helps fluid accumulate at the lung bases, making it easier to locate and remove. Sedation is not usually required for a thoracentesis, so starting an IV line for sedative drugs is unnecessary. Additionally, there are no restrictions on oral intake before the procedure since the patient is not sedated or unconscious. A large collection device to hold 2 to 3 liters of pleural fluid at one time is excessive as usually only 1000 to 1200 mL of pleural fluid is removed to avoid complications like hypotension, hypoxemia, or pulmonary edema. Therefore, the correct choice is to position the patient upright for the procedure.
A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct Answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.