The nurse prioritizes impaired gas exchange as a problem for a client with an asthma exacerbation. Which of the following is the client’s priority goal?
The client will demonstrate decreased episodes of coughing at night.
The client’s pulse oximetry values will remain above 94% on room air for the majority of the time.
The client’s breath sounds will only have slight wheezing by discharge.
The client will correctly demonstrate the use of a peak flow meter.
The Correct Answer is B
Maintaining adequate oxygenation is the primary goal for a client with impaired gas exchange due to an asthma exacerbation. Pulse oximetry is a non-invasive method to monitor the oxygen saturation of a patient’s blood, and values above 94% indicate sufficient oxygenation.
Choice A reason:
The client will demonstrate decreased episodes of coughing at night is important but not the priority goal. While reducing coughing can improve comfort and sleep quality, it does not directly address the critical issue of impaired gas exchange. The primary concern in an asthma exacerbation is ensuring that the client maintains adequate oxygen levels.
Choice B reason:
The client’s pulse oximetry values will remain above 94% on room air for the majority of the time is the priority goal. This goal directly addresses the issue of impaired gas exchange by ensuring that the client maintains adequate oxygenation. Pulse oximetry values above 94% indicate that the client’s blood is sufficiently oxygenated, which is crucial for preventing hypoxemia and ensuring that the body’s tissues receive enough oxygen to function properly.
Choice C reason:
The client’s breath sounds will only have slight wheezing by discharge is a relevant goal but not the priority. While reducing wheezing is an indicator of improved airway function, it is not as directly measurable or critical as maintaining adequate oxygen saturation. Wheezing can persist even when oxygen levels are adequate, so it is not the most reliable indicator of improved gas exchange.
Choice D reason:
The client will correctly demonstrate the use of a peak flow meter is an important educational goal but not the priority in an acute setting. Proper use of a peak flow meter can help the client monitor their asthma and prevent future exacerbations, but it does not directly address the immediate issue of impaired gas exchange. The priority in an acute asthma exacerbation is to ensure that the client is adequately oxygenated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Reducing rebreathing of exhaled air is not a primary characteristic of a Venturi mask. This feature is more associated with non-rebreather masks, which have a one-way valve to prevent exhaled air from being inhaled again.
Choice B reason:
Delivering high percentages of oxygen at flow rates of 10 to 15 L/min is not specific to Venturi masks. Non-rebreather masks are typically used for high oxygen flow rates. Venturi masks are designed to deliver precise oxygen concentrations at lower flow rates.
Choice C reason:
Providing a precise amount of oxygen is the key characteristic of a Venturi mask. Venturi masks are equipped with color-coded adapters that allow for the delivery of specific oxygen concentrations, regardless of the patient’s breathing pattern.
Choice D reason:
Working independently of client breathing factors and flow of oxygen is not entirely accurate. While Venturi masks do provide a consistent oxygen concentration, they still depend on the flow of oxygen set by the healthcare provider.
Correct Answer is ["10"]
Explanation
- 125 units of insulin in 250 mL of normal saline
Step 2: Calculate the concentration of insulin per mL.
- Concentration = 125 units ÷ 250 mL
- Concentration = 0.5 units/mL
Step 3: Determine the required rate of insulin administration.
- Ordered dose = 5 units per hour
Step 4: Calculate the IV flow rate.
- Flow rate (mL/hr) = Ordered dose ÷ Concentration
- Flow rate (mL/hr) = 5 units ÷ 0.5 units/mL
- Flow rate (mL/hr) = 10 mL/hr
The nurse should set the IV pump to 10 mL/hr.
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