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Gas Exchange

Gas Exchange 1 - from Davis Edge Quiz

QuestionAnswer
Which outcome is appropriate for the problem “ineffective gas exchange” for the client recently diagnosed with chronic obstructive pulmonary disease (COPD)? The client demonstrates the correct way to pursed-lip breathe Rational - Pursed-lip breathing helps keep the alveoli open to allow for better oxygen and carbon dioxide exchange.
Which information would the practical nurse expect to be included in the teaching plan for the mother of a child diagnosed with cystic fibrosis (CF)? (Select all that apply) Perform postural drainage and percussion every four (4) hours. Modify activities to accommodate daily physiotherapy. Recognize and report signs and symptoms of respiratory infections. Avoid anyone suspected of having an upper respiratory infection.
he client diagnosed with deep vein thrombosis (DVT) suddenly complains of severe chest pain with a feeling of impending doom. Which complication should the practical nurse suspect the client has experienced? Pulmonary embolus Rational - Part of the clot in the deep veins of the legs dislodges and travels up the inferior vena cava, lodges in the pulmonary artery, and causes the chest pain; the client often feels as if he or she is going to die.
The practical nurse is caring for a client who is anxious, has a respiratory rate of 40, and is complaining of fingers tingling and lips feeling numb. Which intervention should the practical nurse implement first? Have the client take slow, deep breaths - The client is hyperventilating and blowing off too much CO2, which is why her fingers are tingling and her mouth is numb; she needs to retain CO2 by taking slow deep breaths.
The client is admitted to the medical unit diagnosed with a pulmonary embolus (PE). Which intervention would the practical nurse implement from the plan of care? Institute and maintain bed rest, as ordered - Bed rest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus. Bed rest reduces metabolic demands and tissue needs for oxygen in the lungs.
The nurse is caring for a client who has suddenly developed severe shortness of breath and would anticipate that the health-care provider will be inserting a chest tube if the client has which of the following diagnoses? Select all that apply. Pneumothorax & Pleural effusion = A chest tube is used when fluid or air has collected in the pleural space, as in pneumothorax, pleural effusion, penetrating chest injury, or during chest surgery.
The nurse obtained an oxygen saturation reading of 85% on a client who has no other abnormal vital sign values. Which of the following may cause the oxygen saturation to be inaccurate? Select all that apply. The client is moving around the room & The client experienced a smoke inhalation injury & a carbon monoxide injury = It may also be inaccurate in clients who have a smoke inhalation injury, carbon monoxide poisoning, and are dark skinned.
The nurse is aware that pulmonary function tests (PFTs) are used to diagnose and monitor which of the following types of respiratory disorders? Select all that apply. Chronic obstructive pulmonary disease (COPD) & Asthma Rational - Pulmonary function tests are used to diagnose and monitor restrictive (asthma) and obstructive (COPD) lung diseases.
The nurse knows that the x-ray is used to diagnose which of the following complications of a thoracentesis? Pneumothorax - A chest x-ray is usually ordered after a thoracentesis to ensure that the lung was not punctured and deflated (pneumothorax) during the procedure.
The nurse is preparing a client for a thoracentesis and will place the client in which of the following positions for the best results from this treatment? Sitting up with elbows on over the bed table = For a thoracentesis, the client should be placed in a sitting position, bending over a bedside table, or in a side-lying position, if unable to sit.
The nurse is caring for a client who has been unable to cough up secretions and will need to be suctioned. Which of the following vital signs is most important for the nurse to monitor with this client during the procedure? Heart rate Rational - Suctioning can cause hypoxia, vagal stimulation with resulting bradycardia, and even cardiac arrest; therefore, the most important vital sign that should be monitored during the procedure is the heart rate.
A client with severe diarrhea has developed metabolic acidosis. Which of the following respiratory changes does the nurse expect to see as the body attempts to correct the acidosis? Respirations will be fast and deep = Respiratory compensation involves an increase in the rate and depth of respirations, which decreases hydrogen ion formation and raises pH toward normal.
The nurse is caring for a client who is unable to sit up. In which of the following positions will the nurse place the client for auscultation of the posterior chest? Lateral = If a client is unable to be placed in the seated position, side-lying position (lateral) is the preferred position for auscultation of the posterior chest.
The nurse is caring for a client who is experiencing slight shortness of breath (SOB), especially on exertion. What laboratory value is most associated with this client’s symptom? Hgb 8.4 g/dL = because the oxygen molecules are carried in the red cells. A low red cell count would indicate that the client is lacking adequate oxygenation, especially on exertion.
a ventilation-perfusion (VQ) scan, which showed that the affected area of the lung was well ventilated but had no blood supply. Which of the following classifications of medication does the nurse expect the health-care provider to order? Anticoagulant = A VQ scan that shows ventilation without blood supply indicates a possible pulmonary embolism, and the nurse would anticipate the health-care provider ordering an anticoagulant.
Which clinical manifestation would the practical nurse expect to observe in the older adult client diagnosed with pneumonia? Green tenacious sputum = The older adult client does not usually have green tenacious sputum, which is often seen in pneumonia. Older adult clients usually do not have the typical clinical manifestations of the disease process.
Which outcome would be most appropriate for the nursing diagnosis “impaired gas exchange related to increased tenacious sputum” for a client diagnosed with pneumonia? he client’s pulse oximeter reading is greater than 93% = impaired gas exchange.” A pulse oximeter reading of greater than 93% indicates the client is being adequately oxygenated which is an appropriate client outcome.
The practical nurse (PN) is caring for a client with cancer of the lung and has a nursing diagnosis of “impaired gas exchange.” Which intervention would the PN expect to be in the plan of care? Providing small, frequent meals = Clients with lung cancer frequently become fatigued trying to eat, so providing small, frequent meals allows the client to eat throughout the day.