A nurse on a respiratory unit of a hospital is providing care for a client with end-stage lung disease. Consequently, measurement of the client’s arterial blood gases indicates increased PCO 2. Which associated consequence would the nurse anticipate?
Selected Answer:
D.
Higher than normal production of H+
Answers:
A.
Lower than normal production of HCO3
B.
An absence of carbaminohemoglobin
C.
A shift to the left of the oxygen-hemoglobin dissociation curve
D.
Higher than normal production of H+
Response Feedback:
Rationale: As a result of the combination of water and carbon dioxide, hydrogen ions are produced along with bicarbonate. This would be associated with a shift to the right of the oxygen-hemoglobin dissociation curve, increased bicarbonate output, and higher than normal levels of carbaminohemoglobin.
Question 2
2 out of 2 points
The nurse is caring for a 67-year-old client who has been diagnosed with pneumonia. The vital signs are temperature 101.7°F (38.7°C), blood pressure 155/95, respiratory rate 26, and heart rate 88. Which interventions should the nurse incorporate into the client’s plan of care? Select all that apply.
Selected Answers:
A.
Encourage deep breathing and coughing.
C.
Encourage fluid intake.
E.
Administer antipyretics as ordered.
Answers:
A.
Encourage deep breathing and coughing.
B.
Elevate the client’s legs periodically.
C.
Encourage fluid intake.
D.
Administer antitussives as ordered.
E.
Administer antipyretics as ordered.
Response Feedback:
Rationale: The client has a fever, which will cause more water to be lost from the respiratory mucosa. Also, the client has an increased respiratory rate, which will increase these insensible losses. This will result in a thickening of respiratory secretions that will be more difficult to clear. For these reasons, the nurse should encourage fluids, treat fever, and encourage deep breathing and coughing to facilitate clearing secretions from the airway. The client with pneumonia should not routinely be given antitussives as this impedes the protective function of the mucociliary defense system when experiencing a productive cough. Elevating the legs periodically through the day is an intervention to prevent nocturia and paroxysmal nocturnal dyspnea in a client with pedal edema and/or left heart failure; it is not relevant in pneumonia.
Question 3
2 out of 2 points
The emergency department is awaiting the arrival of a client with a spinal cord injury. Knowing the innervation of the diaphragm, a client with which type of injury may be in need of immediate mechanical ventilation? Injury to the:
Selected Answer:
D.
C4 area.
Answers:
A.
T1 area.
B.
T4 area.
C.
C7 area.
D.
C4 area.
Response Feedback:
Rationale: The diaphragm is the principal muscle of inspiration. It is innervated by the phrenic nerve roots, which arise from the cervical level of the spinal cord, mainly from C4 but also C3 and C5.
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