The nurse is caring for a patient who is dyspneic with accessory muscle use, respiratory rate 24 breaths/minute, pulse oximetry 88% on room air, and speaking in phrases. When choosing an oxygen delivery system, which guideline is the most appropriate?

Always use a low flow device such as a nasal cannula or simple face mask.

Correct the PaO2 to a normal level as quickly as possible using mechanical ventilation.

Use continuous positive airway pressure (CPAP) to maintain PaCO2 greater than 50 mmHg.

Increase the PaO2 to an acceptable level at the lowest oxygen concentration possible.

Answer and Explanation

The Correct Answer is D

Choice A reason: Always using a low flow device such as a nasal cannula or simple face mask is not necessarily appropriate for all patients. The choice of device should be based on the patient's oxygen needs and clinical status.

Choice B reason: Correcting the PaO2 to a normal level as quickly as possible using mechanical ventilation is not appropriate in most cases. Rapid correction of oxygen levels can lead to complications such as oxygen toxicity. Mechanical ventilation is used in severe cases but is not the first line of treatment for most patients.

Choice C reason: Using continuous positive airway pressure (CPAP) to maintain PaCO2 greater than 50 mmHg is incorrect. CPAP is used to maintain open airways and improve oxygenation but is not used to target specific PaCO2 levels.

Choice D reason: Increasing the PaO2 to an acceptable level at the lowest oxygen concentration possible is the most appropriate guideline. This approach aims to correct hypoxemia without causing oxygen toxicity. The goal is to achieve adequate oxygenation while minimizing the risk of adverse effects from high oxygen concentrations.

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Correct Answer is C

Explanation

Choice A reason: Shaking the MDI before use is correct technique as it ensures that the medication is properly mixed.

Choice B reason: Exhaling before using the MDI is proper technique as it prepares the lungs for inhalation of the medication.

Choice C reason: Inspiring rapidly when dispensing the medication is incorrect because it can cause the medication to deposit in the mouth or throat rather than reaching the lungs.

Choice D reason: Holding the breath for 10 seconds after inhaling the medication is correct technique as it allows the medication to settle in the lungs.

A. Respiratory alkalosis, uncompensated B. Respiratory acidosis, partially compensated C. Metabolic acidosis, uncompensated D. Metabolic alkalosis, partially compensated

Correct Answer is D

Explanation

Choice A reason: Respiratory alkalosis with uncompensated imbalance would show a low PaCO2, not a normal value.

Choice B reason: Respiratory acidosis with partially compensated imbalance would show a low pH and high PaCO2 with an elevated bicarbonate level.

Choice C reason: Metabolic acidosis with uncompensated imbalance would show a low pH and low bicarbonate level.

Choice D reason: Metabolic alkalosis with partially compensated imbalance is indicated by the elevated pH and bicarbonate level, while

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The nurse is caring for a patient who is dyspneic with accessory muscle use, respiratory rate 24 breaths/minute, pulse oximetry 88% on room air, and speaking in phrases. When choosing an oxygen delivery system, which guideline is the most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is observing a patient using a metered-dose inhaler (MDI) to aid in the management of chronic obstructive pulmonary disease (COPD). Which of the following actions, performed by the patient, indicate that further instruction is needed?

Correct Answer is C

Explanation

The nurse is caring for a patient who is lethargic and dehydrated. Arterial blood gas (ABG) results show pH 7.50, PaO2 85 mmHg, PaCO2 45 mmHg, HCO3 35 mEq/L. What acid-base imbalance will the nurse recognize the patient is at risk for?

Correct Answer is D

Explanation

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