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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Large, bulky stools are not uncommon after a barium enema, as the barium can cause temporary changes in stool consistency and volume. This finding would not necessarily warrant immediate reporting to the healthcare provider unless there are other concerning symptoms.

Choice B reason: Three formed stools in eight hours may indicate increased bowel activity but is not an unusual finding after a barium enema. This would not typically be a cause for concern unless accompanied by other symptoms.

Choice C reason: Streaks of blood present in the stool is a concerning finding that should be reported to the healthcare provider. The presence of blood may indicate mucosal injury, inflammation, or other complications that need to be addressed promptly.

A. pH less than 7.35 B. HCO3 less than 22 mEq/L C. PaCO2 greater than 45 mmHg D. PaO2 less than 80 mmHg E. SpO2 greater than 95%

Correct Answer is ["A","B","C"]

Explanation

Choice A reason: A pH less than 7.35 indicates an acidic state, which is consistent with metabolic acidosis. The normal pH range is 7.35 to 7.45.

Choice B reason: HCO3 (bicarbonate) less than 22 mEq/L indicates a low level of bicarbonate, which is consistent with metabolic acidosis. Bicarbonate is a base, and lower levels indicate a loss of buffering capacity.

Choice C reason: PaCO2 greater than 45 mmHg is not a primary indicator of metabolic acidosis but can occur as a compensatory mechanism in response to respiratory acidosis. The primary indicators of metabolic acidosis are low pH and low bicarbonate.

Choice D reason: PaO2 less than 80 mmHg indicates hypoxemia but is not directly related to the diagnosis of metabolic acidosis. Hypoxemia can occur with various conditions, and while it may be present, it is not a defining characteristic of metabolic acidosis.

Choice E reason: SpO2 greater than 95% indicates normal oxygen saturation and is not relevant to the diagnosis of metabolic acidosis. Oxygen saturation primarily reflects respiratory function rather than acid-base balance.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding will the nurse report to the health care provider?

Correct Answer is C

Explanation

The nurse is caring for a patient with metabolic acidosis. Which laboratory findings will the nurse expect to support this diagnosis? (Select All That Apply)

Correct Answer is ["A","B","C"]

Explanation

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