The nurse provides care to a patient admitted with a respiratory disorder. Which laboratory finding is most concerning?
Oxygen saturation 96%
Blood pH 7.32
Hemoglobin level 12 mg/dL
PaO2 80 mm Hg
The Correct Answer is B
A. Oxygen saturation 96%. This is a normal oxygen saturation level, so it is not a concern.
B. Blood pH 7.32. A pH below 7.35 indicates acidosis, which is concerning in a patient with a respiratory disorder, as it may indicate respiratory failure.
C. Hemoglobin level 12 mg/dL. This is a normal hemoglobin level for most adults and does not indicate a critical problem.
D. PaO2 80 mm Hg. While slightly lower than the normal range (normal is 80–100 mm Hg), this is not the most concerning finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chest physiotherapy (CPT) every 4 hours while awake. CPT is used to mobilize secretions but may be too aggressive for a patient with infiltrates and respiratory distress, as it can increase fatigue and worsen respiratory status.
B. Oxygen therapy via nasal cannula at 3 to 4 L/min. Low-flow oxygen therapy is often used in COPD to prevent hypoxemia while avoiding CO₂ retention.
C. Add humidification to the oxygen source. Humidified oxygen helps prevent airway dryness and improves secretion clearance, which is beneficial for COPD patients.
D. Raise the head of the patient's bed. Elevating the head of the bed promotes lung expansion and improves oxygenation, making this an appropriate intervention.
Correct Answer is D
Explanation
A. Skin breakdown: This is a medical problem or symptom, but it is not a structured nursing diagnosis.
B. Elevated blood pressure: This is a clinical finding rather than a nursing diagnosis.
C. Anxiety: While anxiety is a medical condition, a complete nursing diagnosis should describe the specific effects on the patient, such as "Anxiety related to hospitalization as evidenced by restlessness and increased heart rate."
D. Ineffective breathing pattern: This is a standardized nursing diagnosis as defined by NANDA (North American Nursing Diagnosis Association). It refers to altered respiratory function that nurses can assess and manage.
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