STUVIA 2024/2025
1. Science
2. Medicine
3. Surgery
Respiratory 25,26,27 w/rationales
PaO2 58mmHg
Rat.: nurse should expect to find a low partial pressures of oxygen for a patient who has acute resp.
failure - ✔✔A nurse is caring for a client who has acute respiratory failure. What lab findings should
the nurse expect?
Elevated temp.
Rat.: clients who have emphysema are at risk for the development of pneumonia and other resp.
infections. A nurse should report this as it indicates a possible resp. infection. - ✔✔A nurse is
assessing a client who has emphysema. Which of the following findings should the nurse report to the
provider?
pH 7.30, PO2 80mmHg, PaCO2 55mmHg, HCO3 22mEq/L
%
Rat.: The pH is less than 7.35 and PaCO2 is greater than 45mmHg, which indicates resp. acidosis. -
✔✔A nurse is caring for a client who is postop and has a respiratory rate of 9/min secondary to
general anesthesia effects and incisional pain. What ABG values support the nurses suspicion of
respiratory acidosis?
High fowlers position with arms supported on the overbed table.
Rat.: The nurse should place the client in a position that allows for greater expansion of the chest. -
✔✔A nurse is positioning a client who has emphysema to promote effective breathing. The nurse
should place the client in what position?
"Expect your urine and other secretions to be orange while taking this medication." - ✔✔A nurse is
providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin.
Which of the following instructions should the nurse include?
Tracheal deviation to the unaffected side.
Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse
and forcing the trachea to deviate to the unaffected side - ✔✔A nurse working in th ER is caring for a
stuvia
, STUVIA 2024/2025
client following an acute chest trauma. Which of the following findings indicates tot he nurse the client
is possibly experiencing a tension pneumothorax?
Productive cough with green sputum
Rat.: A nurse should report this as it indicates an infection - ✔✔A nurse is caring for a client who has
COPD. What findings should the nurse report to the provider?
-Wear goggles and mask during the procedure: should wear this to reduce the risk of exposure to
pleural fluid.
-Cleanse the area with an antiseptic solution: this decreases the risk of infection, which is increased
due to the invasive procedure.
-Apply pressure to the site after the needle is withdrawn: this decreases the risk of bleeding at the
needle insertion site - ✔✔A nurse is assisting with a thoracentesis. What actions is appropriate for
the nurse to take when assisting with this procedure?
Administer heparin via continuous IV infusion.
Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority
on stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore,
%
this is the priority intervention. - ✔✔A nurse is caring for a client who has pulmonary embolism.
Which of the following interventions is the priority?
container of sterile water.
Rat.: the nurse should plan to place the open end of the tubing if it becomes disconnected into the
sterile water to prevent a pneumothroax. The tubing and sterile water are then placed below the
clients chest. - ✔✔A nurse is caring for a client who has a chest tube following a lobectomy. Which of
the following items should the nurse keep easily accessible for the client?
Nonrebreather mask
Rat.: this mask is made up of a reservoir bag from which the client obtains the oxygen, a one way
valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that
prevent room air from entering the mask. This delivers greater than 90% FlO2 which provides the
highest level of oxygen. - ✔✔A nurse is caring for a client who is in respiratory distress. What device
should the nurse use to provide the highest level of oxygen via a low-flow system?
A client who is 12hr postop following a total hip arthroplasty
stuvia
1. Science
2. Medicine
3. Surgery
Respiratory 25,26,27 w/rationales
PaO2 58mmHg
Rat.: nurse should expect to find a low partial pressures of oxygen for a patient who has acute resp.
failure - ✔✔A nurse is caring for a client who has acute respiratory failure. What lab findings should
the nurse expect?
Elevated temp.
Rat.: clients who have emphysema are at risk for the development of pneumonia and other resp.
infections. A nurse should report this as it indicates a possible resp. infection. - ✔✔A nurse is
assessing a client who has emphysema. Which of the following findings should the nurse report to the
provider?
pH 7.30, PO2 80mmHg, PaCO2 55mmHg, HCO3 22mEq/L
%
Rat.: The pH is less than 7.35 and PaCO2 is greater than 45mmHg, which indicates resp. acidosis. -
✔✔A nurse is caring for a client who is postop and has a respiratory rate of 9/min secondary to
general anesthesia effects and incisional pain. What ABG values support the nurses suspicion of
respiratory acidosis?
High fowlers position with arms supported on the overbed table.
Rat.: The nurse should place the client in a position that allows for greater expansion of the chest. -
✔✔A nurse is positioning a client who has emphysema to promote effective breathing. The nurse
should place the client in what position?
"Expect your urine and other secretions to be orange while taking this medication." - ✔✔A nurse is
providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin.
Which of the following instructions should the nurse include?
Tracheal deviation to the unaffected side.
Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse
and forcing the trachea to deviate to the unaffected side - ✔✔A nurse working in th ER is caring for a
stuvia
, STUVIA 2024/2025
client following an acute chest trauma. Which of the following findings indicates tot he nurse the client
is possibly experiencing a tension pneumothorax?
Productive cough with green sputum
Rat.: A nurse should report this as it indicates an infection - ✔✔A nurse is caring for a client who has
COPD. What findings should the nurse report to the provider?
-Wear goggles and mask during the procedure: should wear this to reduce the risk of exposure to
pleural fluid.
-Cleanse the area with an antiseptic solution: this decreases the risk of infection, which is increased
due to the invasive procedure.
-Apply pressure to the site after the needle is withdrawn: this decreases the risk of bleeding at the
needle insertion site - ✔✔A nurse is assisting with a thoracentesis. What actions is appropriate for
the nurse to take when assisting with this procedure?
Administer heparin via continuous IV infusion.
Rat.: using the airway, breathing, circulation approach to client care, the nurse should place priority
on stabilizing circulation to the lungs by admin. heparin to prevent further clot formation. Therefore,
%
this is the priority intervention. - ✔✔A nurse is caring for a client who has pulmonary embolism.
Which of the following interventions is the priority?
container of sterile water.
Rat.: the nurse should plan to place the open end of the tubing if it becomes disconnected into the
sterile water to prevent a pneumothroax. The tubing and sterile water are then placed below the
clients chest. - ✔✔A nurse is caring for a client who has a chest tube following a lobectomy. Which of
the following items should the nurse keep easily accessible for the client?
Nonrebreather mask
Rat.: this mask is made up of a reservoir bag from which the client obtains the oxygen, a one way
valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that
prevent room air from entering the mask. This delivers greater than 90% FlO2 which provides the
highest level of oxygen. - ✔✔A nurse is caring for a client who is in respiratory distress. What device
should the nurse use to provide the highest level of oxygen via a low-flow system?
A client who is 12hr postop following a total hip arthroplasty
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