Nokea
The nurse is analyzing a client's blood pH of 7.1. Which symptom would indicate that the client's body is working to stabilize?
- A. Respirations are increasing.
- B. Urine output is decreased.
- C. Heart rate is regular.
- D. WBC count is within normal limits.
Correct Answer: A
Rationale: Increased CO2 mechanism, which is present in body fluids primarily as carbonic acid, causes the pH to decrease below 7.4. As a homeostatic mechanism to normalize pH, the lungs eliminate carbonic acid by blowing off more CO2. Respirations increase to normalize pH. None of the other symptoms note a reflection of stabilizing blood pH.
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What is the difference between respiration and ventilation?
- A. Ventilation is the process of gas exchange.
- B. Ventilation is the movement of air in and out of the respiratory tract.
- C. Ventilation is the process of getting oxygen to the cells.
- D. Ventilation is the exchange of gases in the lung.
Correct Answer: B
Rationale: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
- A. Tickle the back of the throat to produce the gag reflex.
- B. Drink 8 oz of water to thin the secretions for expectoration.
- C. Use the secretions present in the oral cavity.
- D. Take deep breaths and cough forcefully.
Correct Answer: D
Rationale: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should the nurse perform first?
- A. Arterial blood gases
- B. Pulmonary function test
- C. Pulse oximetry
- D. Chest x-ray
Correct Answer: C
Rationale: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
- A. A puncture at the radial artery
- B. The trachea and bronchi
- C. The pleural surfaces
- D. A catheter in the arm vein
Correct Answer: A
Rationale: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla?
- A. They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.
- B. They respond to changes in the O2 levels in the brain.
- C. They respond to changes in CO2 levels in the brain.
- D. They respond to changes in O2 levels and bicarbonate levels in the cerebrospinal fluid.
Correct Answer: A
Rationale: Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. Central chemoreceptors do not respond to changes in the O2 levels in the brain, changes in CO2 levels in the brain, changes in O2 levels, and bicarbonate levels in the cerebrospinal fluid.