Nokea
Which oxygen flow rate is most appropriate for the nurse to administer for this client?
- A. 2 L/minute
- B. 5 L/minute
- C. 8 L/minute
- D. 10 L/minute
Correct Answer: A
Rationale: A low flow rate of 2 L/minute is appropriate for COPD clients to avoid suppressing the hypoxic drive while improving oxygenation.
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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.
A 79-year-old client is admitted to the hospital with a diagnosis of pneumococcal pneumonia. The client has dyspnea. The client's temperature is 102°F, respirations are 36, and pulse is 92. Bed rest is ordered for this client primarily to:
- A. promote thoracic expansion.
- B. prevent the development of atelectasis.
- C. decrease metabolic needs.
- D. prevent infection of others.
Correct Answer: C
Rationale: Bed rest reduces metabolic and oxygen demands in a client with pneumonia and dyspnea, aiding recovery.
When suctioning the airway of a client with a tracheostomy, the nurse applies suction for no longer than how many seconds?
- A. 5 to 7
- B. 10 to 12
- C. 15 to 20
- D. 25 to 30
Correct Answer: B
Rationale: Suctioning for 10 to 12 seconds minimizes the risk of hypoxia and mucosal trauma.
Which nursing observation provides the best evidence that postural drainage is effective?
- A. The client's respiratory rate is increased.
- B. The client's heart rate is much improved.
- C. The client's sputum culture is negative.
- D. The client raises a large volume of sputum.
Correct Answer: D
Rationale: Raising a large volume of sputum indicates that postural drainage is effectively clearing secretions from the airways.
How long after administering a tuberculin skin test should the nurse inspect the client's injection site?
- A. 1 week
- B. 1 day
- C. 2 to 3 days
- D. 4 to 5 days
Correct Answer: C
Rationale: The tuberculin skin test reaction is typically read 48 to 72 hours (2 to 3 days) after administration to assess for induration.