Nokea
The ABG analysis results reveal that the client's partial pressure of arterial carbon dioxide (PaCO2) is 65 mm Hg. The nurse recognizes that this is abnormal because normal PaCO2 levels fall between which values?
- A. 7.35 and 7.45
- B. 80 and 100 mm Hg
- C. 35 and 45 mm Hg
- D. 22 and 26 mm Hg
Correct Answer: C
Rationale: Normal PaCO2 levels are 35 to 45 mm Hg; a value of 65 mm Hg indicates hypercapnia, common in COPD.
You may also like to solve these questions
The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first?
- A. Administer oxygen 10 L via nasal cannula.
- B. Place the client in high Fowler's position.
- C. Obtain a STAT pulse oximeter reading.
- D. Auscultate the client's lung sounds.
Correct Answer: B
Rationale: High Fowler’s position (B) improves breathing in suspected PE, a priority. Oxygen (A), SpO2 (C), and lung sounds (D) follow to support and assess.
The nurse is discussing the results of a tuberculosis skin test. Which explanation should the nurse provide the client?
- A. A red area is a positive reading that means the client has tuberculosis.
- B. The skin test is the only procedure needed to diagnose tuberculosis.
- C. A positive reading means exposure to the tuberculosis bacilli.
- D. Do not get another skin test for one (1) year if the skin test is positive.
Correct Answer: C
Rationale: A positive TB skin test (C) indicates exposure to TB bacilli, not active disease, requiring further testing (e.g., chest X-ray). Redness alone (A) is not diagnostic; induration is measured. The skin test (B) is not definitive for diagnosis. Annual testing (D) may be needed in high-risk groups.
When the client asks the nurse why skin testing is beneficial, which explanation is best?
- A. The symptoms may be related to more than one substance.
- B. Skin testing helps to build up blocking antibodies.
- C. Allergic responses vary from person to person.
- D. The allergy symptoms could become more serious.
Correct Answer: A
Rationale: Skin testing identifies specific allergens causing symptoms, which is crucial when symptoms may be triggered by multiple substances.
The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply.
- A. The client will be able to speak again after the surgery area has healed.
- B. The client should wear a protective covering over the stoma when showering.
- C. The client should clean the stoma and then apply a petroleum-based ointment.
- D. The client should use a humidifier in the room.
- E. The client can get a special telephone for communication.
Correct Answer: B,D,E
Rationale: Showering protection (B), humidifiers (D), and special phones (E) support tracheostomy care. Speech (A) is lost permanently, and petroleum ointment (C) risks infection.
A patient is presenting with chronic obstructive pulmonary disease. The patient has a chronic productive cough with dyspnea on excretion. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. On assessment, the patient has cyanosis in the lips and edema in the abdomen and legs. Based on your nursing knowledge and the patient's symptoms, you suspect the patient suffers from what type of COPD?
- A. Emphysema
- B. Pneumonia
- C. Chronic bronchitis
- D. Pneumothorax
Correct Answer: C
Rationale: Chronic bronchitis , a type of COPD, is characterized by chronic productive cough, hypoxemia, hypercapnia, cyanosis, and edema from right heart failure. Emphysema typically shows barrel chest, pneumonia is an infection, and pneumothorax involves lung collapse.