NUR 210 (M1) – ABGs || all accurately answered.
The client diagnosed with respiratory distress has arterial blood gases of pH 7.45; Paco2 54;
Hco3 25; Pao2 52. Which should the nurse implement? Select all that apply.
1. Apply oxygen via nonrebreather mask.
2. Call the rapid response team (RRT).
3. Elevate the head of the bed.
4. Stay with the client.
5. Notify the health-care provider (HCP). correct answers ALL
Rationale:
The Pao2 level is very low; this client should be placed on a ventilator. The nurse should provide
as much oxygen as possible until this can be done.
The RRT is called when an individual identifies a situation that requires immediate intervention
to prevent the client from going into an arrest situation.
Elevating the HOB allows for better lung expansion.
The nurse should not leave the client but should direct care from the bedside.
The HCP should be notified of the cli- ent's status.
The nurse is caring for clients on a medical unit. Which assessment data indicates a critical
oxygenation problem for the client?
1. The client with an anterior upper left chest
tube is splinting the dressing with a pillow.
2. The male client on oxygen is coughing
forcefully, making it hard to catch his breath.
3. The client who is at rest has circumoral
cyanosis and is difficult to arouse.
4. The female client complains of shortness of
, breath while ambulating in the hallway. correct answers 3. The client who is at rest has
circumoral cyanosis and is difficult to arouse.
Rationale:
1. Chest tubes are painful; splinting the insertion site can help to lessen the pain.
2. Coughing indicates the ability to move air in and out of the lungs. This is not a critical issue.
3. This client with a lack of oxygenation at rest, blueness around the mouth, and who is difficult
to arouse indicates a decrease in neurological functioning. 4. Dyspnea on exertion is not a critical
issue.
The charge nurse receives morning laboratory and respiratory data on the clients. Which data
requires immediate intervention?
1. ABG results of pH 7.35, Paco2 56, Hco3 29,
Pao2 78 for a client diagnosed with COPD.
2. Pulse oximetry reading of 89% on a two-day
postsurgical total knee replacement client.
3. Hgb of 9 g/dL and Hct of 28% on a client
who is receiving the second unit of blood.
4. B-type natriuretic peptide (BNP) of 100 on
a client diagnosed with stage 4 congestive heart failure. correct answers 2. Pulse oximetry
reading of 89% on a two-day
postsurgical total knee replacement client.
Rationale:
1. The body has compensated for the abnormally high level of carbon dioxide (acid) in the blood
by holding on to the base (Hco3) and the pH is within normal range. This is an expected blood
gas for the client with COPD.
2. This pulse oximetry reading indicates an arterial blood oxygen of less than 60. The client
should be seen immediately to prevent respiratory failure.
3. This client is receiving blood to correct the lower levels of H&H.
The client diagnosed with respiratory distress has arterial blood gases of pH 7.45; Paco2 54;
Hco3 25; Pao2 52. Which should the nurse implement? Select all that apply.
1. Apply oxygen via nonrebreather mask.
2. Call the rapid response team (RRT).
3. Elevate the head of the bed.
4. Stay with the client.
5. Notify the health-care provider (HCP). correct answers ALL
Rationale:
The Pao2 level is very low; this client should be placed on a ventilator. The nurse should provide
as much oxygen as possible until this can be done.
The RRT is called when an individual identifies a situation that requires immediate intervention
to prevent the client from going into an arrest situation.
Elevating the HOB allows for better lung expansion.
The nurse should not leave the client but should direct care from the bedside.
The HCP should be notified of the cli- ent's status.
The nurse is caring for clients on a medical unit. Which assessment data indicates a critical
oxygenation problem for the client?
1. The client with an anterior upper left chest
tube is splinting the dressing with a pillow.
2. The male client on oxygen is coughing
forcefully, making it hard to catch his breath.
3. The client who is at rest has circumoral
cyanosis and is difficult to arouse.
4. The female client complains of shortness of
, breath while ambulating in the hallway. correct answers 3. The client who is at rest has
circumoral cyanosis and is difficult to arouse.
Rationale:
1. Chest tubes are painful; splinting the insertion site can help to lessen the pain.
2. Coughing indicates the ability to move air in and out of the lungs. This is not a critical issue.
3. This client with a lack of oxygenation at rest, blueness around the mouth, and who is difficult
to arouse indicates a decrease in neurological functioning. 4. Dyspnea on exertion is not a critical
issue.
The charge nurse receives morning laboratory and respiratory data on the clients. Which data
requires immediate intervention?
1. ABG results of pH 7.35, Paco2 56, Hco3 29,
Pao2 78 for a client diagnosed with COPD.
2. Pulse oximetry reading of 89% on a two-day
postsurgical total knee replacement client.
3. Hgb of 9 g/dL and Hct of 28% on a client
who is receiving the second unit of blood.
4. B-type natriuretic peptide (BNP) of 100 on
a client diagnosed with stage 4 congestive heart failure. correct answers 2. Pulse oximetry
reading of 89% on a two-day
postsurgical total knee replacement client.
Rationale:
1. The body has compensated for the abnormally high level of carbon dioxide (acid) in the blood
by holding on to the base (Hco3) and the pH is within normal range. This is an expected blood
gas for the client with COPD.
2. This pulse oximetry reading indicates an arterial blood oxygen of less than 60. The client
should be seen immediately to prevent respiratory failure.
3. This client is receiving blood to correct the lower levels of H&H.
