A nurse implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Cyanosis noted in nail beds bilaterally.

Lungs clear to auscultation.

Inability to speak in full sentences.

Pulse oximetry 94-96% on room air.

Answer and Explanation

Correct Answer : B,D

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.

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Correct Answer is B

Explanation

Choice A reason:
A respiratory rate of 24/min is slightly elevated, which can be expected in a client with pneumonia due to the body's attempt to increase oxygen intake and carbon dioxide elimination. However, this rate does not directly indicate ineffective airway clearance.

Choice B reason:
A weak, nonproductive cough is a key indicator of ineffective airway clearance. In pneumonia, the presence of secretions in the airways is common, and an effective cough is necessary to clear these secretions. A weak cough that does not produce sputum suggests that the client is unable to clear their airways effectively, which can lead to impaired gas exchange and worsening of symptoms.

Choice C reason:
Pulse oximetry (SpO2) of 90% indicates that the client's oxygen saturation is below the normal range, which is typically between 95-100% for healthy individuals. While this finding is concerning and warrants intervention, it is a result of ineffective airway clearance rather than a direct indicator of it.

Choice D reason:
Shortness of breath with activity is common in clients with pneumonia and can result from various factors, including impaired gas exchange, decreased lung compliance, and increased work of breathing. While it may be associated with ineffective airway clearance, it is not as specific as a weak, nonproductive cough for indicating this particular problem.

A. a negative sputum culture. B. decreased hemoptysis. C. an improved chest x-ray. D. a decreased rate of coughing.

Correct Answer is A

Explanation

Choice A Reason
A negative sputum culture is the most definitive indicator of the effectiveness of tuberculosis (TB) treatment. When a patient with active TB starts on medication, the goal is to eliminate the Mycobacterium tuberculosis bacteria from the body. A sputum culture that turns from positive to negative signifies that the bacteria have been eradicated from the respiratory secretions, indicating successful treatment.

Choice B Reason
While decreased hemoptysis (coughing up blood) is a positive sign and indicates an improvement in the patient's condition, it is not the most reliable parameter for determining the effectiveness of TB therapy. Hemoptysis may decrease as the patient's overall condition improves, but it does not confirm the eradication of the TB bacteria.

Choice C Reason
An improved chest x-ray can show a reduction in the lesions caused by TB, which is a good sign of recovery. However, chest x-rays cannot confirm whether the TB bacteria have been completely eliminated. They are more of a supportive indicator rather than a definitive one.

Choice D Reason
A decreased rate of coughing is another sign that the patient is responding to treatment, as coughing is a primary symptom of TB. However, similar to hemoptysis and chest x-ray improvements, a decrease in coughing does not necessarily mean that the TB bacteria have been fully cleared from the body.

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A nurse implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Nursing Test Bank

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