Nokea
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.
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The nurse is analyzing the results of a patient's arterial blood gases (ABGs). Which of the following findings require the most immediate action?
- A. The arterial oxygen saturation (SaO2) is 92%.
- B. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
- C. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
- D. The bicarbonate level (HCO3-) is 29 mmol/L.
Correct Answer: B
Rationale: All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient's oxygenation.
The nurse is caring for a patient with a persistent cough who has had a bronchoscopy. Which of the following actions should the nurse include in the nursing care plan after the procedure?
- A. Elevate the head of the bed to 80-90 degrees.
- B. Keep the patient NPO until the gag reflex returns.
- C. Place on bed rest for at least 4 hours post-bronchoscopy.
- D. Notify the health care provider about blood-tinged mucus.
Correct Answer: B
Rationale: Because a local anaesthetic is used to suppress the gag or cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high Fowler's position.
The nurse is performing an assessment of the patient's respiratory system. Which of the following parameters is the nurse assessing when using the following illustrated technique?
- A. Bronchophony
- B. Chest expansion
- C. Accessory muscle use
- D. Diaphragmatic excursion
Correct Answer: B
Rationale: Symmetrical chest expansion is confirmed by placement of the hands over the anterior or posterior chest at the same level, observing to confirm is hands and thumbs move equally on both sides with inspiration and expiration.
The nurse is assessing the respiratory system of an older-adult patient. Which of the following findings indicate that the nurse should take immediate action?
- A. The chest appears barrel shaped.
- B. The patient has a weak cough effort.
- C. Crackles are heard from the lung bases to the midline.
- D. Hyperresonance is present across both sides of the chest.
Correct Answer: C
Rationale: Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyper-resonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.
The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) with increasing dyspnea over the last 3 days. Which of the following findings is most important to report to the health care provider?
- A. Respirations are 36 breaths/minute.
- B. Anterior-posterior chest ratio is 1.1.
- C. Lung expansion is decreased bilaterally.
- D. Hyperresonance to percussion is present.
Correct Answer: A
Rationale: The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common persistent changes occurring in patients with COPD.