The nurse is caring for several clients on a respiratory unit. Which client will the nurse see first?
An older adult with an pulse ox of 96% on room air
An adult client with a pulse ox of 94% on room air
A young adult with an arterial oxygen level of 82 on 2 L/min
A young adult with an arterial oxygen level of 94 on room air
The Correct Answer is C
Rationale:
A. This oxygen saturation is within normal limits (95–100%). While age may slightly reduce baseline oxygenation, 96% is acceptable, and the patient is stable. There is no immediate threat to respiratory function, so this patient does not require urgent attention.
B. A saturation of 94% is slightly below normal but generally considered mild hypoxemia. The patient is likely compensating and may not require immediate intervention. Continuous monitoring is appropriate, but urgent evaluation is not required unless symptoms develop.
C. This patient is hypoxemic despite supplemental oxygen, which is more serious than a patient with normal or slightly low oxygen on room air. Normally, PaO2 should rise above 80 mm Hg with supplemental oxygen. Failure to achieve adequate oxygenation on 2 L/min indicates compromised gas exchange, possibly from pneumonia, ARDS, pulmonary embolism, or worsening respiratory failure. This patient is at highest risk for rapid deterioration, making them the priority. Immediate assessment, titration of oxygen, or escalation of care may be required.
D. PaO2 of 94 mm Hg is within normal limits (80–100 mm Hg). This patient is stable and does not require urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Disconnect the drainage system and get a new one is incorrect because simply removing the system leaves the patient at risk for a pneumothorax or tension pneumothorax. Immediate steps must be taken to maintain the water seal.
B. Place the patient in supine position and clamp the tubing is incorrect because clamping a chest tube is generally avoided, especially in a system that is leaking or compromised. Clamping can cause air to accumulate in the pleural space, increasing the risk of tension pneumothorax.
C. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system is correct. This is the priority intervention to maintain the water seal temporarily and prevent air from entering the pleural space while you prepare a replacement system. This step prevents life-threatening complications and stabilizes the patient.
D. Notify the physician immediately is incorrect as the first step because the patient’s safety is at immediate risk. While the physician should be informed, stabilizing the chest tube system takes priority over notification.
Correct Answer is ["B","E"]
Explanation
Rationale:
A. Anxiety and fear usually increase respiratory rate and depth (hyperventilation). Hyperventilation blows off CO2, which can lead to respiratory alkalosis, not acidosis. Therefore, anxiety is not a predisposing factor for respiratory acidosis.
B. CNS depression from conditions such as stroke, brain injury, sedation, or neurologic disease can suppress the respiratory drive, leading to hypoventilation. Hypoventilation results in CO2 retention, which increases PaCO2 and lowers pH, producing respiratory acidosis.
C. DKA causes metabolic acidosis due to the accumulation of ketone bodies. The patient often develops Kussmaul respirations (deep, rapid breathing) to blow off CO2 as a compensatory mechanism, which is opposite of respiratory acidosis.
D. NG suctioning removes gastric acid, which can lead to loss of hydrogen ions, causing metabolic alkalosis, not respiratory acidosis. It does not directly affect CO2 elimination or the respiratory system.
E. Sedatives such as benzodiazepines, opioids, or barbiturates depress the CNS, including the respiratory centers in the medulla. This leads to hypoventilation, decreased alveolar ventilation, and CO2 retention, resulting in respiratory acidosis.
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