Chapter 25: Assessment of Respiratory
System Lewis: Medical-Surgical
Nursing, 10th Edition
A diabetic patient's arterial blood gas (ABG) results are *pH 7.28*; PaCO2 34 mm Hg; PaO2 85
mm Hg; *HCO3- 18* mEq/L. The nurse could expect which locating?
A. Intercostal retractions
c. Low oxygen saturation (SpO2)
b. Kussmaul respirations
d. Decreased venous O2 stress - ANS-b. Kussmaul respirations
Kussmaul (deep and fast) respirations are a compensatory mechanism for metabolic acidosis.
The *low pH and occasional bicarbonate* result indicate *metabolic acidosis*.
Intercostal retractions, a low oxygen saturation fee, and a lower in venous O2 pressure could no
longer be resulting from acidosis.
A affected person admitted to the emergency branch complaining of *unexpected onset
shortness of breath* is identified with a possible *pulmonary embolus*. How need to the nurse
prepare the affected person for diagnostic checking out to confirm the prognosis?
A. Ensure that the patient has been NPO.
B. Start an IV so evaluation media can be given.
C. Inform radiology that radioactive glucose practise is needed.
D. Instruct the patient to anticipate to encourage deeply and exhale forcefully. - ANS-b. Start an
IV so contrast media may be given
*Spiral computed tomography scans* are the maximum commonly used check to *diagnose
pulmonary emboli and contrast media* may be given IV.
A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry
(SpO2) shows that the O2 saturation is ninety four%. Which action need to the nurse anticipate
to take next?
A. Complete a head-to-toe assessment.
B. Administer an inhaled bronchodilator.
C. Place the patient on high-drift oxygen.
D. Obtain repeat arterial blood gases (ABGs). - ANS-c. Place the patient on high-drift oxygen.
, Although the O2 saturation is good enough, the left shift in the oxyhemoglobin dissociation
curve will lower the amount of O2 introduced to tissues, so high oxygen concentrations must
take delivery of.
A patient is scheduled for a computed tomography (CT) test of the chest with evaluation media.
Which evaluation findings should the nurse document to the fitness care company before the
affected person is going for the CT (pick all that follow)?
A. Allergy to shellfish
b. Patient reviews claustrophobia
c. Elevated serum creatinine degree
d. Recent bronchodilator inhaler use
e. Inability to do away with a marriage band - ANS-a, c
a. Allergy to shellfish
c. Elevated serum creatinine degree
Because the contrast media is iodine based and might cause dehydration and decreased renal
blood go with the flow, asking about iodine allergic reactions (consisting of hypersensitive
reaction to shellfish) and tracking renal function before the CT test are essential.
A patient who has a history of persistent obstructive pulmonary ailment *(COPD)* become
hospitalized for *growing shortness of breath and persistent hypoxemia* (SaO2 ranges of 89%
to ninety%). In planning for discharge, which movement with the aid of the nurse may be best in
enhancing compliance with discharge teaching?
A. Have the affected person repeat the commands 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 present in the course of the coaching.
D. Start giving the patient discharge coaching during the admission manner. - ANS-c. Arrange
for the affected person's caregiver to be present in the course of the coaching.
Hypoxemia interferes with the affected person's capacity to study and retain records, so having
the patient's caregiver gift will boom the likelihood that discharge instructions will be
accompanied.
A patient with *acute dyspnea* is scheduled for a spiral computed tomography *(CT) test*.
Which statistics obtained by means of the nurse is a *priority to talk 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 assessment media is used during a spiral CT, the affected person might
also want to have the CT scan without assessment or be premedicated earlier than injection of
the evaluation media
A affected person with a *persistent cough* is scheduled to have a *bronchoscopy with biopsy*.
Which intervention will the nurse enforce at once after the technique?
System Lewis: Medical-Surgical
Nursing, 10th Edition
A diabetic patient's arterial blood gas (ABG) results are *pH 7.28*; PaCO2 34 mm Hg; PaO2 85
mm Hg; *HCO3- 18* mEq/L. The nurse could expect which locating?
A. Intercostal retractions
c. Low oxygen saturation (SpO2)
b. Kussmaul respirations
d. Decreased venous O2 stress - ANS-b. Kussmaul respirations
Kussmaul (deep and fast) respirations are a compensatory mechanism for metabolic acidosis.
The *low pH and occasional bicarbonate* result indicate *metabolic acidosis*.
Intercostal retractions, a low oxygen saturation fee, and a lower in venous O2 pressure could no
longer be resulting from acidosis.
A affected person admitted to the emergency branch complaining of *unexpected onset
shortness of breath* is identified with a possible *pulmonary embolus*. How need to the nurse
prepare the affected person for diagnostic checking out to confirm the prognosis?
A. Ensure that the patient has been NPO.
B. Start an IV so evaluation media can be given.
C. Inform radiology that radioactive glucose practise is needed.
D. Instruct the patient to anticipate to encourage deeply and exhale forcefully. - ANS-b. Start an
IV so contrast media may be given
*Spiral computed tomography scans* are the maximum commonly used check to *diagnose
pulmonary emboli and contrast media* may be given IV.
A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry
(SpO2) shows that the O2 saturation is ninety four%. Which action need to the nurse anticipate
to take next?
A. Complete a head-to-toe assessment.
B. Administer an inhaled bronchodilator.
C. Place the patient on high-drift oxygen.
D. Obtain repeat arterial blood gases (ABGs). - ANS-c. Place the patient on high-drift oxygen.
, Although the O2 saturation is good enough, the left shift in the oxyhemoglobin dissociation
curve will lower the amount of O2 introduced to tissues, so high oxygen concentrations must
take delivery of.
A patient is scheduled for a computed tomography (CT) test of the chest with evaluation media.
Which evaluation findings should the nurse document to the fitness care company before the
affected person is going for the CT (pick all that follow)?
A. Allergy to shellfish
b. Patient reviews claustrophobia
c. Elevated serum creatinine degree
d. Recent bronchodilator inhaler use
e. Inability to do away with a marriage band - ANS-a, c
a. Allergy to shellfish
c. Elevated serum creatinine degree
Because the contrast media is iodine based and might cause dehydration and decreased renal
blood go with the flow, asking about iodine allergic reactions (consisting of hypersensitive
reaction to shellfish) and tracking renal function before the CT test are essential.
A patient who has a history of persistent obstructive pulmonary ailment *(COPD)* become
hospitalized for *growing shortness of breath and persistent hypoxemia* (SaO2 ranges of 89%
to ninety%). In planning for discharge, which movement with the aid of the nurse may be best in
enhancing compliance with discharge teaching?
A. Have the affected person repeat the commands 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 present in the course of the coaching.
D. Start giving the patient discharge coaching during the admission manner. - ANS-c. Arrange
for the affected person's caregiver to be present in the course of the coaching.
Hypoxemia interferes with the affected person's capacity to study and retain records, so having
the patient's caregiver gift will boom the likelihood that discharge instructions will be
accompanied.
A patient with *acute dyspnea* is scheduled for a spiral computed tomography *(CT) test*.
Which statistics obtained by means of the nurse is a *priority to talk 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 assessment media is used during a spiral CT, the affected person might
also want to have the CT scan without assessment or be premedicated earlier than injection of
the evaluation media
A affected person with a *persistent cough* is scheduled to have a *bronchoscopy with biopsy*.
Which intervention will the nurse enforce at once after the technique?
