Nokea
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.
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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.
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.
A nurse is instructing the client on the normal sensations that can occur when contrast medium is infused during pulmonary angiography. Which client statement demonstrates an understanding of the teaching?
- A. I will feel a dull pain when the catheter is introduced.'
- B. I will feel light-headed when the contrast medium is introduced.'
- C. I will feel waves of nausea throughout the procedure.'
- D. I will feel warm and may have chest pain'
Correct Answer: D
Rationale: During a pulmonary angiography, a contrast medium is injected into the femoral circulation. When the medium is infused, the client will feel warm and flushed, with a possibility of chest pain. The client will feel pressure when the catheter is inserted. The client does not typically feel light-headed or nauseated during this procedure.
What happens to the diaphragm during inspiration?
- A. It relaxes and raises.
- B. It contracts and flattens.
- C. It relaxes and flattens.
- D. It contracts and raises.
Correct Answer: B
Rationale: During inspiration, the diaphragm contracts and flattens, which expands the thoracic cage and increases the thoracic cavity.
The nurse is caring for a client in the immediate post-thoracentesis period. In which position is the client placed?
- A. In the supine position
- B. Lying on the unaffected side
- C. In the high Fowler's position
- D. Prone with a pillow under the head
Correct Answer: B
Rationale: Following a thoracentesis, the client remains on bed rest and typically lies on the unaffected side for at least 1 hour to promote expansion of the lung on the affected side. Lying flat in a supine position or prone does not promote expansion of the lung.