A nurse reviews the ABG values and notes a pH of 7.50, a PCO2 of 30 mm Hg, and an HCO3 of 25 mEq/L. The nurse interprets these values as indicating:
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Solution
Respiratory alkalosis uncompensated
In respiratory alkalosis, the pH will be higher than normal and the PCO2 will be low.
A nurse instructs a client to use the pursed lip method of breathing. The client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed lip breathing is:
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Solution
Promote carbon dioxide elimination
Pursed lip breathing facilitates maximum expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation.
The nurse reviews the ABG values of a client. The results indicate respiratory acidosis. Which of the following values would indicate that this acid-base imbalance exists?
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Solution
pH of 7.30
A nurse is caring for a client with emphysema. The client is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed
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Solution
2 L/min
One to 3 L/min of oxygen by nasal cannula may be required to raise to PaO2 to 60 to 80 mm Hg. However, oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in normal respiratory system.
Theophylline (Theo-Dur) tablets are prescribed for a client with chronic airflow limitation, and the nurse instructs the client about the medication. Which statement by the client indicates a need for further teaching?
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Solution
“I will take the medication on an empty stomach.”
Theo-Dur is a bronchodilator. The medication should be administered with food such as milk and crackers to prevent GI irritation.
An oxygenated delivery system is prescribed for a client with COPD to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?
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Solution
Venturi mask
The venture mask delivers the most accurate oxygen concentration. The Venturi mask is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, the aerosol mask, and the tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.
A nurse is caring for a client hospitalized with acute exacerbation of COPD. Which of the following would the nurse expect to note on assessment of this client?
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Solution
A hyperinflated chest on x-ray film
Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray films reveal a hyperinflated chest and a flattened diaphragm is the disease is advanced.
An unconscious client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, and a normal oxygen level. An elevated potassium level is also present. These results indicate the presence of:
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Solution
Metabolic acidosis
In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the pH would indicate a metabolic state.
A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate decreases. Which of the following is the most appropriate nursing intervention?
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Solution
Stop the procedure and reoxygenated the client
During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in HR resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, this procedure is stopped and the client is reoxygenated.
A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning to a maximum of:
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Solution
10 seconds
Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells within the heart. A vasovagal response may occur causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.