Nokea
The partial pressure of oxygen in arterial blood is approximately
- A. 40 mm Hg
- B. 100 mm Hg
- C. 50 mm Hg
- D. 70 mm Hg
Correct Answer: B
Rationale: The correct answer is B: 100 mm Hg. In arterial blood, the partial pressure of oxygen is typically around 100 mm Hg due to the oxygen-rich environment in the lungs. This value represents the pressure exerted by oxygen molecules in the blood. Choices A, C, and D are incorrect because they do not align with the normal range of oxygen partial pressure in arterial blood, which is around 100 mm Hg. Option A is too low, option C is slightly below the normal range, and option D is slightly above the normal range. Therefore, B is the most accurate representation of the typical partial pressure of oxygen in arterial blood.
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How is a client positioned for a thoracentesis?
- A. The client sits at the side of the bed.
- B. The client lies on the affected side.
- C. The client lies flat on the back.
- D. The client lies down with the head raised.
Correct Answer: A
Rationale: The correct answer is A. For thoracentesis, the client typically sits at the edge of the bed, leaning forward with arms supported on a table or over their knees to spread out the intercostal spaces and stabilize the chest wall. B is incorrect because lying on the affected side would compress the area being accessed. C is wrong as lying flat reduces access to the pleural space. D is incorrect because raising the head is not standard positioning for this procedure.
A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height and weight
- D. Occupation and hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation and hobbies. This is the highest priority information for the nurse to obtain because it can provide crucial insights into potential respiratory risks or exposures (e.g., smoking, exposure to fumes or pollutants). Understanding the client's occupation and hobbies helps the nurse assess the impact on respiratory health and tailor interventions accordingly.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status.
B: Neck circumference may be relevant for assessing airway patency in certain conditions, but occupation and hobbies are more pertinent.
C: Height and weight are important for general health assessment but do not directly impact respiratory status as much as occupation and hobbies.
Which of the following age-based changes is false?
- A. The lungs lose elastic tissue
- B. The lung's compliance changes
- C. Vital capacity increases
- D. Respiratory muscles weaken
Correct Answer: C
Rationale: The correct answer is C because vital capacity actually decreases with age due to changes in lung elasticity and muscle strength. A is correct as aging causes the lungs to lose elastic tissue. B is correct as lung compliance changes with age. D is correct as respiratory muscles weaken over time. Therefore, only option C is false in the context of age-related changes in lung function.
A client with pneumonia has a fever of 101.4° F (38.6° C) a nonproductive cough and an O2 saturation of 88%. The client is weak and needs assistance to get out of bed. Which client problem should the nurse assign as the priority?
- A. Fatigue
- B. Hyperthermia
- C. Impaired mobility
- D. Impaired gas exchange
Correct Answer: D
Rationale: The correct answer is D, Impaired gas exchange. This is the priority because the client's O2 saturation of 88% indicates poor oxygenation, which can lead to serious complications like hypoxemia. The fever and nonproductive cough are symptoms of pneumonia contributing to impaired gas exchange. Addressing this issue is crucial to prevent respiratory distress.
A: Fatigue - While important, fatigue is a secondary concern compared to impaired gas exchange, which directly affects oxygenation and can be life-threatening.
B: Hyperthermia - The client's fever is likely related to the pneumonia but managing impaired gas exchange takes precedence as it directly impacts oxygen delivery to tissues.
C: Impaired mobility - While assisting the client out of bed is necessary, the priority is to address the underlying problem of impaired gas exchange to prevent respiratory compromise.
A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.