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A nurse is preparing to assist a provider to withdraw arterial blood from
a client's radial artery for measurement of ABG. Which of the following
actions should the nurse plan to take? - ANSWER -check the circulation
in the client's ulnar artery prior to obtaining the specimen - the nurse
should ensure that circulation to the hand is adequate from the ulnar
artery in case the radial artery is injured from the blood draw. The most
common site for withdrawal of arterial blood gases is the radial artery
- the nurse should not administer oxygen prior to the blood draw,
because the test measures the client's blood gases when breathing room
air
- the nurse should use ice to preserve the arterial blood gas specimen
during transport to the laboratory. If the sample is not placed on ice, the
ph and PO2 values can be inaccurate. It is not necessary to place ice to
the withdrawal site
- the nurse should apply pressure to the puncture site for 5 to 10 min
after the needle is withdrawn. High pressure of the blood in the arteries
places the client at risk for hemorrhage from the withdrawal site
A nurse is reinforcing teaching about pursed-lip breathing for a client
who has COPD and emphysema. The nurse should explain that this
breathing technique does which of the following? - ANSWER -keeps
the airways open on exhalation - the client who has COPD with
emphysema should use pursed-lip breathing when experiencing dyspnea.
This is one of the simplest ways to control dyspnea. It slows the client's
pace of breathing and keeps the airway open on exhalation, making each
, breath more effective. Pursed-lip breathing releases trapped air in the
lungs and prolongs exhalation to slow the breathing rate. This improved
breathing pattern moves carbon dioxide out of the lungs more efficiently
- the client who uses pursed-lip breathing prolongs exhalation, rather
than increasing oxygen intake on inhalation. Increase oxygen cautiously
because the client depends on low oxygen to stimulate breathing
- the client should use pursed-lip breathing breathes in through the
nares and out through pursed lips, rather than concentrating on using
chestwall muscles
- the client who uses pursed-lip breathing breathes in through the
nares and out through the pursed lips, rather than concentrating on using
the diaphragm
A nurse is reinforcing preoperative teaching with a client who is to
undergo a pneumonectomy. The client states, "I am afraid it will hurt to
cough after the surgery." which of the following statements should the
nurse make? - ANSWER -"I will show you how to splint your incision
while coughing." - the client who has a pneumonectomy must cough to
clear secretions from the remaining lung. The nurse should show the
client how to splint her incision to reduce pain when coughing
- the client who had a pneumonectomy must cough to clear
secretions from the remaining lung
- pain medication reduces pain to a tolerable level. However, it does
not necessarily keep the client pain-free. Additionally, telling the client