The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange?
The client demonstrates effective coughing and deep breathing exercises.
Current arterial blood gas results are a pH 7.30, PaCO2 48 mm Hg, HCO3-25 mEq/L (25 mmol/L), and a PaO2 75 mm Hg.
The client's heart rate is 82 beats/minute and respiratory rate is 16 breaths/minute.
An oxygen saturation reading of 96% is obtained using pulse oximetry.
The Correct Answer is D
A. The client demonstrates effective coughing and deep breathing exercises: While this indicates the client is participating in lung expansion strategies, it does not directly confirm the adequacy of gas exchange.
B. Current arterial blood gas results are a pH 7.30, PaCO₂ 48 mm Hg, HCO₃⁻ 25 mEq/L, and PaO₂ 75 mm Hg: These values indicate respiratory acidosis (low pH and elevated CO₂) with mild hypoxemia (PaO₂ < 80 mm Hg). This ABG profile shows impaired gas exchange and inadequate ventilation postoperatively.
C. The client’s heart rate is 82 beats/minute and respiratory rate is 16 breaths/minute: Normal vital signs are encouraging but do not necessarily reflect the effectiveness of gas exchange. A client can have normal rates but still have inadequate oxygenation or ventilation.
D. An oxygen saturation reading of 96% is obtained using pulse oximetry: A SpO₂ of 96% indicates effective oxygenation and is a direct, noninvasive measure of gas exchange. It reflects that hemoglobin is adequately saturated with oxygen, supporting the conclusion of sufficient pulmonary function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
A. I will keep my nitroglycerin tablets with me all the time: This is appropriate and essential for clients at risk for angina. Having immediate access to nitroglycerin ensures timely administration at the onset of chest pain.
B. I will chew my nitroglycerin tabs as soon as pain begins: Nitroglycerin tablets should never be chewed or swallowed. They are sublingual and must dissolve under the tongue to be rapidly absorbed through the mucosa for immediate effect. Chewing the tablet reduces effectiveness and delays pain relief.
C. I will call 911 if there is no improvement in my chest pain after taking nitroglycerin: Emergency services should be contacted if pain persists after one dose. This statement reflects proper understanding of when to seek urgent care during a possible cardiac event.
D. I will take the nitroglycerin 1 or 2 more times 10 minutes apart if pain does not get better: Sublingual nitroglycerin should be taken every 5 minutes, not 10 minutes, for a maximum of 3 doses. Delaying additional doses may prolong ischemia and increase the risk of myocardial damage during an acute episode.
E. I will wait 5 minutes after taking my nitroglycerin to see if the pain improves: Evaluating pain relief after 5 minutes is consistent with recommended protocols. If pain persists, a second dose may be taken, followed by a third dose 5 minutes later if needed.
F. I will lie down or sit if I start to feel any chest discomfort: This helps reduce myocardial oxygen demand and prevent injury from dizziness due to nitroglycerin-induced hypotension. It’s a safe and appropriate action.
G. I will wear a medication alert bracelet to indicate my history of heart problems: Medical ID jewelry is recommended for clients with cardiovascular history to inform emergency responders about potential cardiac conditions and medications.
Correct Answer is A
Explanation
A. A description of the chest pain when client is at rest: Determining whether the pain occurs at rest helps differentiate stable from unstable angina. Stable angina typically resolves with rest and is exertion-related, while pain at rest may suggest unstable angina.
B. A demonstration of the activity that precipitates pain: While understanding what provokes the pain is helpful, a physical demonstration is unnecessary and potentially dangerous, especially if it might trigger another anginal episode.
C. A complete seven (7) day diet history of client's oral intake: Dietary intake is not immediately relevant for evaluating recent angina symptoms. Priority should be placed on identifying acute features that may signal unstable angina or myocardial infarction.
D. The client’s blood pressures sitting and standing: Assessing for orthostatic hypotension is useful in evaluating dizziness or syncope but does not directly address the nature or severity of chest pain. It is not the priority assessment for symptoms of angina pectoris following exertion.
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