A patient has a diagnosis of Impaired Gas Exchange. Which assessment finding shows that the interventions have been effective?
The patient's Spo2 is 97% on 2L NC
The patient appears comfortable
The patient is coughing up copious white sputum
The patient is able to move out of bed without difficulty
The Correct Answer is A
A. The patient's Spo2 is 97% on 2L NC:
This assessment finding indicates that the patient's oxygen saturation level (SpO2) is 97% while receiving 2 liters per minute of oxygen via nasal cannula. Oxygen saturation is a measure of the percentage of hemoglobin saturated with oxygen in the blood. A SpO2 level of 97% suggests adequate oxygenation, which is essential for effective gas exchange. Therefore, if the patient's SpO2 is within the target range on the prescribed oxygen therapy, it indicates that the interventions aimed at improving gas exchange have been effective.
B. The patient appears comfortable:
While patient comfort is important, it is not a direct indicator of effective gas exchange. A patient may appear comfortable for various reasons, such as pain relief, proper positioning, or emotional support, but this does not necessarily reflect improved gas exchange. Therefore, while comfort is an important aspect of nursing care, it is not specifically indicative of the effectiveness of interventions for impaired gas exchange.
C. The patient is coughing up copious white sputum:
The presence of copious white sputum does not directly indicate improved gas exchange. White sputum may suggest various conditions, such as respiratory tract infections or inflammation, but it does not provide direct information about gas exchange efficiency. Effective gas exchange involves the exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, which cannot be assessed solely based on sputum production.
D. The patient is able to move out of bed without difficulty:
The ability to move out of bed without difficulty may indicate improved overall physical function or mobility, but it does not specifically reflect improved gas exchange. Gas exchange primarily involves the transfer of oxygen from the alveoli into the bloodstream and the removal of carbon dioxide from the bloodstream into the alveoli for exhalation. While improved gas exchange may lead to enhanced physical endurance and reduced dyspnea, the ability to move out of bed without difficulty is not a direct measure of gas exchange efficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Encourage the client to drink 8 glasses of water a day.
This is the correct choice. Clients with COPD often have thickened respiratory secretions due to chronic inflammation and mucus production. Adequate hydration helps to keep these secretions thin, making them easier to cough up and clear from the airways. Encouraging the client to drink plenty of fluids, such as water, can assist in maintaining optimal hydration levels and promoting effective airway clearance.
B. Instruct the client to cough every 4 hours.
Instructing the client to cough on a scheduled basis, such as every 4 hours, is not appropriate for managing COPD. While coughing is important for clearing respiratory secretions, the frequency of coughing should be based on the client's individual needs and symptoms. Some clients with COPD may need to cough more frequently, while others may need to cough less often. It's important to encourage the client to cough as needed to clear secretions rather than on a predetermined schedule.
C. Provide the client with a low-protein diet.
Providing the client with a low-protein diet is not recommended for managing COPD. Adequate protein intake is important for maintaining muscle strength, including respiratory muscles, and supporting overall health. Clients with COPD may have increased energy needs due to the increased work of breathing and should be encouraged to consume a balanced diet that includes adequate protein.
D. Advise the client to lie down after eating.
Advising the client to lie down after eating is not recommended for managing COPD. Lying down after eating can increase pressure on the diaphragm and make breathing more difficult, especially for individuals with compromised lung function. It's generally recommended for individuals with COPD to remain in an upright position after eating to minimize respiratory discomfort and reduce the risk of aspiration.
Correct Answer is B
Explanation
A. Notify the provider.
This choice suggests involving the healthcare provider immediately. While notifying the provider might eventually be necessary if the issue persists, it's not the initial action in this scenario. The nurse should first assess and troubleshoot the situation before escalating it to the provider.
B. Verify that the suction regulator is on.
This is the correct choice. When there is no bubbling in the suction control chamber of a chest tube, it may indicate that suction is not being applied properly. Verifying that the suction regulator is turned on and set to the correct level ensures that suction is being delivered to the chest tube.
C. Continue to monitor the client because this is an expected finding.
This choice is incorrect. The absence of bubbling in the suction control chamber is not an expected finding and suggests a potential problem with the suction system. Ignoring this finding without taking any action could lead to complications for the client.
D. Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Milking the chest tube is a technique used to maintain patency and promote drainage in chest tubes, but it should not be the first action when there is no bubbling in the suction control chamber. This action does not address the underlying issue of inadequate suction and may not be appropriate without first ensuring that suction is functioning correctly.
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