Nokea
The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion?
- A. The client's arterial blood gases are within normal limits.
- B. The client appears anxious, has dyspnea, and is tachypneic.
- C. The client has intercostal retractions and is using accessory muscles.
- D. The client has bilateral lung sounds with crackles and rhonchi.
Correct Answer: C
Rationale: Intercostal retractions and accessory muscle use (C) indicate severe respiratory distress, consistent with ARDS due to increased work of breathing from reduced lung compliance. Normal ABGs (A) contradict ARDS, which involves hypoxia. Anxiety, dyspnea, and tachypnea (B) are non-specific. Crackles and rhonchi (D) may occur but are less specific than physical signs of distress.
You may also like to solve these questions
You're caring for a patient with pneumonia. The patient has just started treatment for pneumonia and is still experiencing hypoxemia. You know that respiratory acidosis is very common with patients with pneumonia. Which arterial blood gases below represent respiratory acidosis that is NOT compensated?
- A. pH 7.29, PaCO2 55, HCO3 23, PO2 85
- B. pH 7.48, PaCO2 35, HCO3 22, PO2 85
- C. pH 7.20, PaCO2 20, HCO3 28, PO2 85
- D. pH 7.55, PaCO 63, HCO3 19, PO2 85
Correct Answer: A
Rationale: Respiratory acidosis is characterized by low pH (<7.35) and high PaCO2 (>45). Option A (pH 7.29, PaCO2 55, HCO3 23) shows uncompensated respiratory acidosis, as HCO3 is normal, indicating no renal compensation. Other options show normal pH, respiratory alkalosis, or invalid data.
Which laboratory tests should the client receive before prophylactic drug therapy for tuberculosis is started?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Aspartate aminotransferase (AST; SGOT) and alanine aminotransferase (ALT; SGPT)
- C. Complete blood count (CBC) and hematocrit
- D. White blood cell (WBC) count and urinalysis
Correct Answer: B
Rationale: Liver function tests (AST and ALT) are essential before starting tuberculosis prophylaxis, as drugs like isoniazid can cause hepatotoxicity.
A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in precautions and will always wear when providing patient care?
- A. droplet, respirator
- B. airborne, respirator
- C. contact and airborne, surgical mask
- D. droplet, surgical mask
Correct Answer: B
Rationale: A patient with ACTIVE TB is contagious. The bacterium, mycobacterium tuberculosis which causes TB, is so small that it can stay suspended in the air for hours to days. Therefore, the nurse will place the patient in AIRBORNE precautions. In addition, a special mask must be worn called a respirator (as referred to as an N95 mask.....a surgical mask does NOT work with this condition).
Which nursing rationale best explains the reason for using a cuffed tracheostomy tube on the client?
- A. The cuff prevents skin breakdown.
- B. The cuff prevents aspiration.
- C. The cuff is more comfortable.
- D. The cuff reduces infection.
Correct Answer: B
Rationale: The cuff on a tracheostomy tube seals the airway, preventing aspiration of secretions or food into the lungs.
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?
- A. The client has no signs of respiratory distress.
- B. The client shows an improved respiratory pattern.
- C. The client demonstrates intolerance to activity.
- D. The client participates in establishing goals.
Correct Answer: C
Rationale: Activity intolerance (C) indicates poor COPD control, requiring plan revision. No distress (A), improved breathing (B), and goal participation (D) are positive outcomes.