Nokea
The nurse is caring for a patient with a metabolic acidosis of unknown origin. Which of the following findings should the nurse expect based on this diagnosis?
- A. Intercostal retractions
- B. Kussmaul's respirations
- C. Low oxygen saturation (SpO2)
- D. Decrease in venous O2 pressure
Correct Answer: B
Rationale: Kussmaul's (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PO2 would not be caused by acidosis.
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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 reviewing a patient's laboratory results and identifies which of the following values as a normal tidal volume?
- A. 100 mL
- B. 250 mL
- C. 500 mL
- D. 1000 mL
Correct Answer: C
Rationale: The normal tidal volume is 500 mL.
The nurse is admitting a patient with acute shortness of breath. Which of the following actions should the nurse take during the initial assessment of the patient?
- A. Complete a full physical examination to determine the systemic effect of the respiratory distress.
- B. Obtain a comprehensive health history to determine the extent of any prior respiratory condition.
- C. Delay the physical assessment and ask family members about any history of respiratory conditions.
- D. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.
Correct Answer: D
Rationale: When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patient's history of medical problems, the patient is the best informant for these data.
The nurse is caring for a patient with respiratory disease and observes that the patient's SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Document the response to exercise.
- C. Administer the PRN supplemental O2.
- D. Encourage the patient to pace activity.
Correct Answer: C
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.
Which of the following respiratory assessments are not normal? (Select all that apply.)
- A. Respirations 23 breaths/minute
- B. Outward movement of abdomen during inspiration
- C. Increase in vibrations with tactile fremitus
- D. Tripod position
- E. Symmetrical chest expansion
Correct Answer: A,C,D
Rationale: Respirations greater than 20 breaths/minute indicate tachypnea. Tactile fremitus is often increased in pneumonia and pulmonary edema. The tripod position is assumed in patients with COPD, asthma in exacerbation and pulmonary edema. Outward movement of the abdomen during inspiration is normal. Symmetrical chest expansion is normal.