A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs if noted in the client should be reported immediately to the physician?
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Solution
Bronchospasm
If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and arrhythmias. Hematuria is unrelated to this procedure.
A nurse is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen?
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Solution
Having the client take 3 deep breaths.
To obtain a sputum specimen, the client should rinse the mouth to prevent contamination, breathe deeply, and then cough unto a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.
A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen’s test on the client. Number in order of priority the steps for performing the Allen’s test (#1 is first step).
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Solution
Answer: 5, 2, 1, 4, and then 3.
A nurse is caring for a client with renal failure. Blood gas results indicate a pH of 7.30; a PCO2 of 32 mm Hg, and a bicarbonate concentration of 20 mEq/L. The nurse has determined that the client is experiencing metabolic acidosis. Which of the following laboratory values would the nurse expect to note?
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Solution
Potassium level of 5.2 mEq/L
Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul’s respirations; headache; N/V, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; CNS depression, including mental dullness, drowsiness, stupor, and coma; twitching, and coma. Hyperkalemia will occur.
A nurse understands that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?
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Solution
Metabolic alkalosis
Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause metabolic alkalosis.
A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse observe?
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Solution
Respirations that are abnormally deep, regular, and increased in rate.
Kussmaul’s respirations are abnormally deep, regular, and increased in rate.
A nurse is caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder?
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Solution
Metabolic acidosis
Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes or an ileostomy or with diarrhea. These conditions result in metabolic acidosis.
A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?
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Solution
Metabolic alkalosis
Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid.
A client is scheduled for blood to be drawn from the radial artery for an ABG determination. Before the blood is drawn, an Allen’s test is performed to determine the adequacy of the:
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Solution
Ulnar circulation
Before radial puncture for obtaining an ABG, you should perform an Allen’s test to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury o the hand if damage to the radial artery occurs with arterial puncture.
A nurse reviews the arterial blood gas results of a patient and notes the following: pH 7.45; PCO2 30 mm Hg; and bicarbonate concentration of 22 mEq/L. The nurse analyzes these results as indicating:
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Solution
Respiratory alkalosis, compensated.
The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite (see-saw) will be seen between the pH and the PCO2. In this situation, the pH is at the high end of the normal value and the PCO2 is low. In an alkalotic condition, the pH is up. Therefore, the values identified in the question indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, compensation has occurred.