A client with pneumonia is dyspneic, and the nurse positions the client in a high Fowler's position. The oxygen flow rate is 3 L/minute, and the client's pulse oximeter reading is 96%. An hour later the pulse oximeter reading is 88%. Which action should the nurse take first?

Collect a specimen for an arterial blood gas (ABG).

Report the findings to the healthcare provider.

Evaluate the client's white blood cell count (WBC).

Increase the flow rate of oxygen administration.

Answer and Explanation

The Correct Answer is D

A. Collect a specimen for an arterial blood gas (ABG): While ABG provide detailed information on oxygenation and acid-base status, the process takes time and does not provide immediate correction for hypoxemia. The priority is to stabilize the client's oxygen saturation first.

B. Report the findings to the healthcare provider: Notifying the provider is important, but immediate nursing interventions to correct the hypoxemia should take precedence. The drop in oxygen saturation needs to be addressed before escalation.

C. Evaluate the client’s white blood cell count (WBC): WBC levels help assess infection severity but do not assist with immediate respiratory distress or oxygenation. This is a secondary concern when managing acute hypoxia.

D. Increase the flow rate of oxygen administration: A pulse oximetry reading of 88% indicates hypoxemia. The most urgent action is to increase the oxygen flow rate to improve oxygenation. This is a rapid, nurse-initiated intervention that addresses the client’s saturation.

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Correct Answer is ["A","C","E","F"]

Explanation

A. Atrial and ventricular rates are 115 beats/minute: Sinus tachycardia is defined by a heart rate greater than 100 beats/minute with normal sinus rhythm. The atrial and ventricular rates remain equal and typically range between 100–150 beats/minute in sinus tachycardia.

B. There is a wide QRS complex: Wide QRS complexes (>0.12 seconds) are not typical of sinus tachycardia and suggest an abnormal ventricular conduction, such as bundle branch block or ventricular rhythm, which is not supported by the sinus origin in this case.

C. The PP interval is regular: Regular PP intervals indicate consistent atrial depolarization, which is a hallmark of sinus rhythms, including sinus tachycardia. This reflects a stable and predictable SA node discharge.

D. The PR interval measures 0.12 seconds: A normal PR interval ranges from 0.12 to 0.20 seconds, and in sinus tachycardia, the PR interval remains within this normal range despite the faster rate.

E. There is absence of P waves: P waves are present and upright in leads II, III, and aVF during sinus tachycardia. Absence of P waves would suggest an atrial arrhythmia such as atrial fibrillation, not sinus tachycardia.

F. The QRS complex measures 0.08 seconds: A narrow QRS complex (<0.12 seconds) confirms that ventricular depolarization is occurring through the normal conduction pathways, which is typical in sinus tachycardia.

A. PaO2 60 mm Hg. B. pH 7.30. C. HCO3 26 mEq/L (26 mmol/L). D. PaCO2 80 mm Hg.

Correct Answer is D

Explanation

A. PaO₂ 60 mm Hg: A PaO₂ of 60 mm Hg indicates moderate hypoxemia, which is concerning but not the most direct marker of respiratory depression. It reflects impaired oxygenation, but CO₂ retention is more closely associated with respiratory arrest risk.

B. pH 7.30: A pH of 7.30 shows mild acidemia, which may result from respiratory or metabolic causes. While this indicates some imbalance, it does not specifically point to the severity of respiratory depression as much as rising CO₂ levels do.

C. HCO₃ 26 mEq/L (26 mmol/L): This bicarbonate value is within the normal range and does not suggest acute metabolic compensation or decompensation. It offers limited insight into the acute respiratory depression caused by sedatives like midazolam and fentanyl.

D. PaCO₂ 80 mm Hg: This significantly elevated PaCO₂ indicates severe hypoventilation and respiratory depression. Such a high carbon dioxide level can suppress central respiratory drive, impair consciousness, and quickly progress to respiratory arrest if not promptly reversed.

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A client with pneumonia is dyspneic, and the nurse positions the client in a high Fowler's position. The oxygen flow rate is 3 L/minute, and the client's pulse oximeter reading is 96%. An hour later the pulse oximeter reading is 88%. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

Exhibits The client's electrocardiogram (ECG) strip reveals sinus tachycardia. Select the 4 characteristics that the nurse is likely to see in the ECG.

Correct Answer is ["A","C","E","F"]

Explanation

Correct Answer is D

Explanation

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A client with pneumonia is dyspneic, and the nurse positions the client in a high Fowler's position. The oxygen flow rate is 3 L/minute, and the client's pulse oximeter reading is 96%. An hour later the pulse oximeter reading is 88%. Which action should the nurse take first?

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