Nokea
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.
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The nurse is suctioning a client who is unable to expectorate respiratory secretions. At which point does the nurse expect the client to experience coughing?
- A. When the catheter reaches the back of the pharynx
- B. When the catheter enters the main bronchus of the lung
- C. When the catheter reaches the point of the carina
- D. When the catheter tickles the uvula
Correct Answer: C
Rationale: Upon the catheter stimulating the carina, coughing and even bronchospasm may occur. Productive secretions may be loosened and eliminated via the suction catheter. When the catheter reaches the back of the pharynx near the uvula, the gag reflex is initiated. The suction catheter does not reach the entrance of the lung.
The nurse is caring for a client with hypoxemia of unknown cause. Which oxygen transport consideration(s) does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.
- A. Oxygen is dissolved.
- B. High blood pressure disrupts oxygen transport.
- C. Oxyhemoglobin circulates to the body tissue.
- D. All systemic oxygen is available for diffusion.
- E. Adequate red blood cells are needed for oxygen transport.
Correct Answer: A,C,E
Rationale: Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for oxygen transport. High blood pressure does not disrupt transport unless there is disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form which can diffuse across cell membranes.
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.
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
- A. The two methods of perfusion are the bronchial and alveolar circulation.
- B. The two methods of perfusion are the bronchial and capillary circulation.
- C. The two methods of perfusion are the bronchial and pulmonary circulation.
- D. The two methods of perfusion are the alveolar and pulmonary circulation.
Correct Answer: C
Rationale: The two methods of perfusion are the bronchial and pulmonary circulation. There is no alveolar circulation. Capillaries are the vessels that perform the perfusion regardless of which area of the lung they are in.
The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
- A. Blood gases
- B. Complete blood count
- C. Blood chemistry
- D. Serum alkaline phosphate
Correct Answer: A
Rationale: Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders.