Chapter 25: Assessment of Respiratory
System Lewis: Medical-Surgical
Nursing, 10th Edition
A diabetic affected person's arterial blood gas (ABG) effects are *pH 7.28*; PaCO2 34 mm Hg;
PaO2 eighty five mm Hg; *HCO3- 18* mEq/L. The nurse could count on which locating?
A. Intercostal retractions
c. Low oxygen saturation (SpO2)
b. Kussmaul respirations
d. Decreased venous O2 pressure - ANS-b. Kussmaul respirations
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
The *low pH and low bicarbonate* result imply *metabolic acidosis*.
Intercostal retractions, a low oxygen saturation charge, and a lower in venous O2 strain could
now not be caused by acidosis.
A patient admitted to the emergency department complaining of *sudden onset shortness of
breath* is identified with a probable *pulmonary embolus*. How need to the nurse put together
the affected person for diagnostic trying out to affirm the diagnosis?
A. Ensure that the affected person has been NPO.
B. Start an IV so assessment media can be given.
C. Inform radiology that radioactive glucose coaching is needed.
D. Instruct the affected person to anticipate to inspire deeply and exhale forcefully. - ANS-b.
Start an IV so evaluation media may be given
*Spiral computed tomography scans* are the maximum typically used test to *diagnose
pulmonary emboli and comparison media* may be given IV.
A affected person in metabolic alkalosis is admitted to the emergency department and pulse
oximetry (SpO2) shows that the O2 saturation is ninety four%. Which movement need to the
nurse count on to take next?
A. Complete a head-to-toe assessment.
B. Administer an inhaled bronchodilator.
C. Place the patient on excessive-flow oxygen.
D. Obtain repeat arterial blood gases (ABGs). - ANS-c. Place the affected person on
excessive-flow oxygen.
, Although the O2 saturation is good enough, the left shift within the oxyhemoglobin dissociation
curve will decrease the amount of O2 brought to tissues, so excessive oxygen concentrations
have to accept.
A patient is scheduled for a computed tomography (CT) experiment of the chest with
comparison media. Which assessment findings need to the nurse report to the health care
provider before the affected person is going for the CT (pick out all that observe)?
A. Allergy to shellfish
b. Patient reviews claustrophobia
c. Elevated serum creatinine level
d. Recent bronchodilator inhaler use
e. Inability to get rid of a marriage band - ANS-a, c
a. Allergy to shellfish
c. Elevated serum creatinine level
Because the evaluation media is iodine based totally and may reason dehydration and
decreased renal blood glide, asking approximately iodine hypersensitive reactions (inclusive of
hypersensitive reaction to shellfish) and monitoring renal characteristic earlier than the CT
experiment are necessary.
A patient who has a records of chronic obstructive pulmonary disease *(COPD)* turned into
hospitalized for *increasing shortness of breath and persistent hypoxemia* (SaO2 stages of
89% to ninety%). In making plans for discharge, which motion by using the nurse might be
handiest in enhancing compliance with discharge coaching?
A. Have the affected person repeat the instructions without delay after teaching.
B. Accomplish the affected person coaching simply earlier than the scheduled discharge.
C. Arrange for the affected person's caregiver to be gift throughout the coaching.
D. Start giving the patient discharge teaching all through the admission manner. - ANS-c.
Arrange for the patient's caregiver to be present in the course of the coaching.
Hypoxemia interferes with the affected person's capacity to research and retain facts, so having
the patient's caregiver gift will growth the probability that discharge instructions could be
followed.
A affected person with *acute dyspnea* is scheduled for a spiral computed tomography *(CT)
experiment*. Which statistics received by means of the nurse is a *precedence to communicate
to the health care issuer* earlier than the CT?
A. Allergy to shellfish
c. Respiratory rate of 30
b. Apical pulse of 104
d. O2 saturation of 90% - ANS-a. Allergy to shellfish
Because iodine-based totally assessment media is used for the duration of a spiral CT, the
patient can also want to have the CT experiment with out comparison or be premedicated
before injection of the evaluation media
System Lewis: Medical-Surgical
Nursing, 10th Edition
A diabetic affected person's arterial blood gas (ABG) effects are *pH 7.28*; PaCO2 34 mm Hg;
PaO2 eighty five mm Hg; *HCO3- 18* mEq/L. The nurse could count on which locating?
A. Intercostal retractions
c. Low oxygen saturation (SpO2)
b. Kussmaul respirations
d. Decreased venous O2 pressure - ANS-b. Kussmaul respirations
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
The *low pH and low bicarbonate* result imply *metabolic acidosis*.
Intercostal retractions, a low oxygen saturation charge, and a lower in venous O2 strain could
now not be caused by acidosis.
A patient admitted to the emergency department complaining of *sudden onset shortness of
breath* is identified with a probable *pulmonary embolus*. How need to the nurse put together
the affected person for diagnostic trying out to affirm the diagnosis?
A. Ensure that the affected person has been NPO.
B. Start an IV so assessment media can be given.
C. Inform radiology that radioactive glucose coaching is needed.
D. Instruct the affected person to anticipate to inspire deeply and exhale forcefully. - ANS-b.
Start an IV so evaluation media may be given
*Spiral computed tomography scans* are the maximum typically used test to *diagnose
pulmonary emboli and comparison media* may be given IV.
A affected person in metabolic alkalosis is admitted to the emergency department and pulse
oximetry (SpO2) shows that the O2 saturation is ninety four%. Which movement need to the
nurse count on to take next?
A. Complete a head-to-toe assessment.
B. Administer an inhaled bronchodilator.
C. Place the patient on excessive-flow oxygen.
D. Obtain repeat arterial blood gases (ABGs). - ANS-c. Place the affected person on
excessive-flow oxygen.
, Although the O2 saturation is good enough, the left shift within the oxyhemoglobin dissociation
curve will decrease the amount of O2 brought to tissues, so excessive oxygen concentrations
have to accept.
A patient is scheduled for a computed tomography (CT) experiment of the chest with
comparison media. Which assessment findings need to the nurse report to the health care
provider before the affected person is going for the CT (pick out all that observe)?
A. Allergy to shellfish
b. Patient reviews claustrophobia
c. Elevated serum creatinine level
d. Recent bronchodilator inhaler use
e. Inability to get rid of a marriage band - ANS-a, c
a. Allergy to shellfish
c. Elevated serum creatinine level
Because the evaluation media is iodine based totally and may reason dehydration and
decreased renal blood glide, asking approximately iodine hypersensitive reactions (inclusive of
hypersensitive reaction to shellfish) and monitoring renal characteristic earlier than the CT
experiment are necessary.
A patient who has a records of chronic obstructive pulmonary disease *(COPD)* turned into
hospitalized for *increasing shortness of breath and persistent hypoxemia* (SaO2 stages of
89% to ninety%). In making plans for discharge, which motion by using the nurse might be
handiest in enhancing compliance with discharge coaching?
A. Have the affected person repeat the instructions without delay after teaching.
B. Accomplish the affected person coaching simply earlier than the scheduled discharge.
C. Arrange for the affected person's caregiver to be gift throughout the coaching.
D. Start giving the patient discharge teaching all through the admission manner. - ANS-c.
Arrange for the patient's caregiver to be present in the course of the coaching.
Hypoxemia interferes with the affected person's capacity to research and retain facts, so having
the patient's caregiver gift will growth the probability that discharge instructions could be
followed.
A affected person with *acute dyspnea* is scheduled for a spiral computed tomography *(CT)
experiment*. Which statistics received by means of the nurse is a *precedence to communicate
to the health care issuer* earlier than the CT?
A. Allergy to shellfish
c. Respiratory rate of 30
b. Apical pulse of 104
d. O2 saturation of 90% - ANS-a. Allergy to shellfish
Because iodine-based totally assessment media is used for the duration of a spiral CT, the
patient can also want to have the CT experiment with out comparison or be premedicated
before injection of the evaluation media
