Nokea
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with asthma. Which of the following patients require the most rapid action by the nurse?
- A. 20-year-old with ABG results: pH 7.28, PaCO2: 60 mm Hg, and PaO2: 58 mm Hg.
- B. 32-year-old with ABG results: pH 7.30, PaCO2: 30 mm Hg, and PaO2: 65 mm Hg.
- C. 40-year-old with ABG results: pH 7.34, PaCO2: 33 mm Hg, and PaO2: 80 mm Hg.
- D. 64-year-old with ABG results: pH 7.31, PaCO2: 58 mm Hg, and PaO2: 64 mm Hg.
Correct Answer: A
Rationale: The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible, but do not require interventions as quickly as the 20-year-old.
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A young adult patient with cystic fibrosis (CF) tells the nurse that she is considering having a child. Which of the following responses is best for the nurse to respond initially?
- A. Are you aware of the normal lifespan for patients with CF?'
- B. Do you need any information to help you with the decision?'
- C. You will need to have genetic counselling before making a decision.'
- D. Many women with CF do not have difficulty in conceiving children.'
Correct Answer: B
Rationale: The nurse's initial response should be to assess the patient's knowledge level and need for information. Although the lifespan for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patient's comments. The other responses are accurate, but the nurse should first assess the patient's understanding about the issues surrounding pregnancy.
The nurse is caring for a patient with a history of asthma. Which of the following assessment findings should the nurse communicate immediately to the health care provider?
- A. Pulse oximetry reading of 94%.
- B. Respiratory rate of 26 breaths/minute.
- C. Use of accessory muscles in breathing.
- D. Peak expiratory flow rate of 240 mL/minute.
Correct Answer: C
Rationale: Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.
Which of the following topics should the nurse include in medication teaching for a patient with newly diagnosed persistent asthma?
- A. Use of long-acting β-adrenergic medications.
- B. Adverse effects of sustained-release theophylline.
- C. Self-administration of inhaled corticosteroids.
- D. Complications associated with oxygen therapy.
Correct Answer: C
Rationale: Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.
The nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which of the following findings is the best indicator that the therapy has been effective?
- A. No wheezes are audible.
- B. Oxygen saturation is >95%.
- C. Accessory muscle use has decreased.
- D. Respiratory rate is 16 breaths/minute.
Correct Answer: B
Rationale: The goal for treatment of an asthma attack is to keep the oxygen saturation >92%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen through a Venturi mask. Which of the following actions should the nurse take?
- A. Ensure that the oxygen flow is at least 10 L/min.
- B. Keep the air entrainment ports free of obstruction.
- C. Attach a humidifier to the oxygen delivery system.
- D. Drain condensation from the oxygen tubing every hour.
Correct Answer: B
Rationale: The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or nonrebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation.