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The nurse has just received arterial blood gas (ABG) results on four patients. Which of the following results is considered normal?
- A. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90%
- B. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 95%
- C. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98%
- D. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%
Correct Answer: B
Rationale: These ABGs indicate normal values: pH 7.35-7.45, PaO2 75-100 mm Hg, PaCO2 35-45 mm Hg, and O2 saturation 95-100%.
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The nurse is preparing a patient with a right-sided pleural effusion for a thoracentesis. Which of the following positions should the nurse position the patient?
- A. Supine with the head of the bed elevated 45 degrees
- B. In the Trendelenburg position with both arms extended
- C. On the left side with the right arm extended above the head
- D. Sitting upright with the arms supported on an over bed table
Correct Answer: D
Rationale: The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.
The nurse is admitting a patient who is hypothermic with a O2 saturation of 96%. Which of the following actions should the nurse take next?
- A. Initiate rewarming of the patient.
- B. Complete a head-to-toe assessment.
- C. Obtain arterial blood gases (ABGs).
- D. Place the patient on high-flow oxygen.
Correct Answer: D
Rationale: Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the patient is normothermic. The other actions also are appropriate, but the initial action should be to administer oxygen.
The nurse is auscultaining a patient's lungs and hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. Which of the following information should the nurse document?
- A. Expiratory crackles at the bases
- B. Expiratory wheezes in both lung bases
- C. Abnormal lung sounds in the bases of both lungs
- D. Pleural friction rub in the right and left lower lobes
Correct Answer: B
Rationale: Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovescular sounds heard in the peripheral lung fields. Crackles are low-pitched, 'bubbling' sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
The nurse is palpating the posterior chest of a patient while the patient says '99' and notes that no vibration is felt. Which of the following information should the nurse document?
- A. Diminished expansion
- B. Dullness to percussion
- C. Absent tactile fremitus
- D. Decreased breath sounds
Correct Answer: C
Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99.' Different techniques are used to assess for dullness to percussion, decreased breath sounds, and diminished expansion.
The nurse is caring for a patient with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?
- A. Intercostal retractions
- B. Kussmaul's respirations
- C. Low oxygen saturation (SpO2)
- D. Decrease in venous O2 pressure
Correct Answer: B
Rationale: Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PO2 would not be caused by acidosis.