ch 19 Flashcards
The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange?
a. Blood glucose of 350 mg/dL
b. Anticoagulant therapy for 10 days
c. Hemoglobin of 8.5 g/dL
d. Heart rate of 100 beats/min and blood pressure of 100/60
ANS: C
The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.
The nurse is reviewing the patient’s arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What might the nurse expect to observe on assessment of this patient?
a. Disorientation and tremors
b. Tachycardia and decreased blood pressure
c. Increased anxiety and irritability
d. Hyperventilation and lethargy
ANS: A
The patient is experiencing respiratory acidosis (↓pH and ↑PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.
The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem?
a. Peripheral arterial disease of the lower extremities
b. Chronic obstructive pulmonary disease (COPD)
c. Chronic asthma
d. Severe anemia secondary to chemotherapy
ANS: A
Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.
The nurse is assessing a patient’s differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient’s gas exchange?
a. An elevation of the total white cell count indicates generalized inflammation.
b. Eosinophil count will assist to identify the presence of a respiratory infection.
c. White cell count will differentiate types of respiratory bacteria.
d. Level of neutrophils provides guidelines to monitor a chronic infection.
ANS: A
Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient’s gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis?
a. Chronic lung disease with increased carbon dioxide retention
b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention
c. Decreased cardiac output with increased serum lactic acid production
d. Gastric drainage with increased removal of gastric acid
ANS: A
Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.
Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen?
a. Hemoglobin level of 8.0
b. Bronchoconstriction and mucus
c. Peripheral arterial disease
d. Decreased thoracic expansion
ANS: A
Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk?
a. The infant is becoming more active.
b. There is an increase in intake of breast milk or formula.
c. The infant is unable to maintain an adequate iron intake.
d. A depletion of fetal hemoglobin occurs.
ANS: D
Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2–3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.
Which clinical management prevention concept would the nurse identify as representative of secondary prevention?
a. Decreasing venous stasis and risk for pulmonary emboli
b. Implementation of strict hand washing routines
c. Maintaining current vaccination schedules
d. Prevention of pneumonia in patients with chronic lung disease
ANS: D
Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications.
The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.)
a. Neurologic system
b. Endocrine system
c. Pulmonary system
d. Immune system
e. Cardiovascular system
f. Hepatic system
ANS: A, C, E
The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.)
a. Respiratory rate is 24 breaths/min.
b. Oxygen saturation level is 98%.
c. The right side of the thorax expands slightly more than the left.
d. Trachea is just to the left of the sternal notch.
e. Nail beds are pink with good capillary refill.
f. There is presence of quiet, effortless breath sounds at lung base bilaterally.
ANS: B, E, F
Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.
