A client is experiencing confusion and tremors is admitted to a nursing unit. An initial ABG report indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely experiencing:
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Solution
Carbon dioxide narcosis
Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possible coma.
Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client’s history, would require physician notification?
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Solution
Hepatitis B
Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury.
A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood level exists if which of the following were noted in the laboratory report?
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Solution
15 mcg/mL
The therapeutic theophylline blood level range from 10-20 mcg/mL.
A community health nurse is conducting an educational session with community members regarding TB. The nurse tells the group that one of the first symptoms associated with TB is:
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Solution
A cough with the expectoration of mucoid sputum
One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum.
A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority?
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Solution
Ineffective airway clearance related to retained secretions.
Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.
A 76-year old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no signs of respiratory distress. Which of the following is a normal physiologic change related to aging?
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Solution
Decreased vital capacity.
Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase is residual volume.
A police officer brings in a homeless client to the ER. A chest x-ray suggests he has TB. The physician orders an intradermal injection of 5 tuberculin units/0.1 ml of tuberculin purified derivative. Which needle is appropriate for this injection?
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Solution
½” to 3/8” 26 or 27G needle.
Intradermal injections like those used in TN skin tests are administered in small volumes (usually 0.5 ml or less) into the outer skin layers to produce a local effect. A TB syringe with a ½” to 3/8” 26G or 27G needle should be inserted about 1/8” below the epidermis.
A client’s ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and HCO3- of 24 mEq/L. What do these values indicate?
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Solution
Respiratory acidosis
An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct?
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Solution
Using intermittent suction while withdrawing the catheter.
Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia, suctioning shouldn’t last more than 10-seconds at a time. Suction shouldn’t be applied while the catheter is being advanced.
A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. Which action should the nurse take?
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Solution
Remove the airway and insert a shorter one.
If a client gags or coughs after nasopharyngeal airway placement, the tube may be too long. The nurse should remove it and insert a shorter one. Simply repositioning the airway won’t solve the problem. The client won’t get used to the tube because it’s the wrong size. Suctioning without a nasopharyngeal airway causes trauma to the natural airway.