Nokea
Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM?
- A. pH 7.38, Pao2 94, Paco2 44, Hco3 24.
- B. pH 7.46, Pao2 82, Paco2 34, Hco3 22.
- C. pH 7.48, Pao2 59, Paco2 30, Hco3 26.
- D. pH 7.33, Pao2 94, Paco2 44, Hco3 20.
Correct Answer: C
Rationale: ARDS is characterized by severe hypoxemia despite high oxygen delivery. Pao2 59 (C) despite 10 LPM oxygen indicates refractory hypoxia, a hallmark of ARDS. Normal Pao2 (94 in A and D) contradicts ARDS. Pao2 82 (B) is low but not as severe as 59, making C the best indicator of ARDS.
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Where on the client should the nurse position the sensor of the pulse oximeter to obtain an accurate measurement?
- A. Apply it to the client's finger.
- B. Apply it to the client's palm.
- C. Clip it to the client's earlobe.
- D. Wrap it around the client's leg.
Correct Answer: A
Rationale: The finger is the most common and reliable site for pulse oximetry, providing accurate oxygenation readings.
When administering oxygen to the client through a partial rebreathing mask, which observation is most important for the nurse to report to the respiratory therapy department?
- A. Moisture is accumulating inside the mask.
- B. The bag collapses during inspiration.
- C. The mask covers the client's mouth and nose.
- D. The strap around the client's head is snug.
Correct Answer: B
Rationale: A collapsing bag during inspiration indicates inadequate oxygen flow, which must be reported to ensure proper oxygen delivery.
The nurse provides directions to the client on the proper use of a peak flow meter. Arrange the steps for the nurse's instruction to the client on the proper use of a peak flow meter in the correct sequence.
- A. Slide the marker to zero.
- B. Take a deep breath.
- C. Put the mouthpiece of the flow meter into your mouth.
- D. Blow out as fast as you can.
- E. Empty all of the air from your lungs.
- F. Record the highest rating after the current sequence.
Correct Answer: A, B, C, D, E, F
Rationale: The correct sequence is: 1. Slide the marker to zero, 2. Take a deep breath, 3. Put the mouthpiece in your mouth, 4. Blow out as fast as you can, 5. Empty all of the air from your lungs, 6. Record the highest rating.
You're developing a plan of care for a patient who is at risk for the development of a deep vein thrombosis after surgery. What nursing intervention below would the nurse NOT include in the patient's plan of care to prevent DVT formation?
- A. The patient will eat all meals out of the bed daily by sitting in the bedside chair.
- B. The nurse will apply sequential compression devices (SCDs) per physician's order to the patient's lower extremities every night at bedtime.
- C. The nurse will administer per physician's order Enoxaparin in the subcutaneous tissue of the abdomen.
- D. The patient will ambulate daily.
Correct Answer: B
Rationale: Yes, the nurse would apply SCDs per MD order to help prevent DVTs, BUT they are to be applied and worn by the patient anytime they are in bed or sitting. The only time a patient should not wear the SCDs is when they're ambulating. Therefore, the nurse would NOT just apply them at bedtime but during the day too.
A patient's D-dimer result is <500 ng/mL (FEU). The nurse knows that the D-dimer assesses and this result means?
- A. fibrin degradation fragment; positive for a blood clot
- B. platelet degradation protein; negative for a blood clot
- C. clotting factors; positive for a blood clot
- D. fibrin degradation fragment; negative for a blood clot
Correct Answer: D
Rationale: A d-dimer test assess fibrin degradation fragment. This test doesn't tell us where the clot may be (so it not specific) so it will need to be further investigated by the MD and a positive result doesn't necessarily mean the patient has a clot because some disease processes can cause a false positive. Also, a normal d-dimer is <500 ng/mL (FEU). However, it depends on how the lab reports the assay cut-off value for the d-dimer. Some labs have a cutoff <250 ng/mL (D-DU). However, <500 ng/mL (FEU) is equivalent to <250 ng/mL (D-DU).