Gas Exchange
A nurse is caring for a client with pneumonia who is experiencing shortness of breath and decreased oxygen saturation. Which of the following interventions should the nurse perform first?
A. Increase IV fluid rate
B. Encourage deep breathing and coughing
C. Raise the head of the bed
D. Administer an antipyretic
C. Raise the head of the bed
A nurse is teaching a client with COPD about home oxygen use. Which of the following statements indicates understanding?
A. "I will set my oxygen to 6 L/min when I feel short of breath."
B. "I will clean my nasal cannula once a week."
C. "I will use petroleum jelly to soothe nasal dryness."
D. "I will avoid smoking while using oxygen."
D. "I will avoid smoking while using oxygen."
A nurse is teaching a client with multiple sclerosis about strategies to reduce fatigue. Which of the following should the nurse include?
A. Take hot showers daily.
B. Avoid daytime naps.
C. Group activities in the morning.
D. Increase fluid intake in the evening.
C. Group activities in the morning.
A nurse is assessing a client with a stage 3 pressure injury. Which of the following findings should the nurse expect?
A. Intact skin with non-blanchable redness
B. Full-thickness tissue loss with visible fat
C. Partial-thickness loss of dermis
D. Exposed bone or tendon
B. Full-thickness tissue loss with visible fat
A nurse is reviewing ABG results for a client with COPD. Which of the following results indicates respiratory acidosis?
A. pH 7.50, PaCO2 30 mmHg
B. pH 7.30, PaCO2 50 mmHg
C. pH 7.45, HCO3 22 mEq/L
D. pH 7.60, HCO3 30 mEq/L
B. pH 7.30, PaCO2 50 mmHg
A nurse is assessing a client with COPD. Which of the following findings should the nurse report to the provider immediately?
A. Productive cough with white sputum
B. O2 saturation of 91% on room air
C. Use of accessory muscles during breathing
D. New onset of confusion
A nurse is caring for a client with pneumonia. Which nursing intervention promotes oxygenation?
A. Encouraging fluid restriction
B. Elevating the head of the bed
C. Limiting movement to conserve energy
D. Applying warm compresses to the chest
B. Elevating the head of the bed
A client with Parkinson’s disease is at risk for falls. Which of the following actions should the nurse take?
A. Encourage quick movements.
B. Place the bed in high position.
C. Use throw rugs for better grip.
D. Provide a walker for ambulation.
D. Provide a walker for ambulation.
Which of the following interventions helps prevent pressure injuries in immobile clients?
A. Reposition every 4 hours
B. Massage reddened areas
C. Use donut-type cushions
D. Maintain HOB at or below 30 degrees
D. Maintain HOB at or below 30 degrees
Which of the following conditions is most likely to cause metabolic acidosis?
A. Vomiting
B. Diuretic use
C. Renal failure
D. Hyperventilation
C. Renal failure
Which diagnostic test is most appropriate to confirm a diagnosis of tuberculosis?
A. Peak flow measurement
B. Chest x-ray
C. PPD skin test
D. Sputum culture for acid-fast bacilli
D. Sputum culture for acid-fast bacilli
A nurse is evaluating a client with asthma who has been prescribed a corticosteroid inhaler. Which of the following findings indicates improved oxygenation?
A. Increased respiratory rate
B. Use of accessory muscles
C. Clear lung sounds
D. Persistent wheezing
C. Clear lung sounds
Which of the following findings should the nurse expect in a client with myasthenia gravis?
A. Involuntary jerking movements
B. Muscle rigidity
C. Ptosis and dysphagia
D. Tremor at rest
C. Ptosis and dysphagia
A client presents with cellulitis. Which assessment finding requires immediate intervention?
A. Warmth and redness of the skin
B. Localized swelling and tenderness
C. Increased pain and red streaks
D. Fever of 100.8°F
C. Increased pain and red streaks
A nurse is caring for a client with pneumonia who is hypoventilating. Which acid-base imbalance should the nurse monitor for?
A. Respiratory alkalosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory acidosis
D. Respiratory acidosis
A client with asthma is experiencing wheezing and shortness of breath. Which medication should the nurse anticipate administering?
A. Montelukast
B. Salmeterol
C. Albuterol
D. Fluticasone
C. Albuterol
Which of the following assessments indicates that oxygen therapy is effective in a client with COPD?
A. Heart rate of 110 bpm
B. Oxygen saturation of 95%
C. RR of 26 breaths/min
D. Cyanosis of lips and fingertips
B. Oxygen saturation of 95%
A nurse is caring for a client with multiple sclerosis who reports new onset of blurry vision. What should the nurse do first?
A. Encourage rest periods
B. Notify the provider
C. Document the finding
D. Administer prescribed medication
B. Notify the provider
Which of the following is the most appropriate dressing for a pressure injury with slough?
A. Dry sterile dressing
B. Transparent film
C. Hydrocolloid dressing
D. Antiseptic soaked gauze
C. Hydrocolloid dressing
Which of the following lab values confirms metabolic alkalosis?
A. pH 7.50, HCO3 30 mEq/L
B. pH 7.30, PaCO2 55 mmHg
C. pH 7.25, HCO3 18 mEq/L
D. pH 7.45, PaCO2 40 mmHg
A. pH 7.50, HCO3 30 mEq/L
Which of the following symptoms is a common sign of impaired gas exchange in an elderly client with pneumonia?
A. Chest pain
B. Increased sputum production
C. Lethargy and confusion
D. Hemoptysis
C. Lethargy and confusion
A nurse is reinforcing teaching with a client with asthma about the use of a peak flow meter. Which of the following instructions should the nurse include?
A. Use the peak flow meter before using your rescue inhaler.
B. Take your peak flow reading once a week.
C. Exhale slowly into the mouthpiece.
D. Record the highest reading of three attempts.
D. Record the highest reading of three attempts.
A client is in myasthenic crisis. Which of the following interventions is the priority?
A. Administer corticosteroids
B. Monitor blood glucose
C. Assess respiratory status
D. Initiate physical therapy
C. Assess respiratory status
A client is diagnosed with malignant melanoma. Which characteristic is most concerning?
A. Lesion diameter of 4 mm
B. Symmetrical mole
C. Color change in lesion
D. Clearly defined border
C. Color change in lesion
A nurse is reviewing a client’s ABG: pH 7.31, PaCO2 60 mmHg, HCO3 24 mEq/L. Which condition is present?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
C. Respiratory acidosis