Quiz 2

1.On admission the client's ABG values were pH 7.
20, PaO2 64 mmHg, PaCO2 60

mmHg, and HCO3 22 mEq/L. A chest tube is inserted, and oxygen at 4
liters/minute is started. Thirsty minutes later, his repeat blood gas values are pH
7.30, PaO2 76, PaCO2 50, and HCO3 22 mEq/L. This change would indicate.
(0/1 Point)
impending respiratory failure
improving respiratory status
developing respiratory alkalosis
obstruction in the chest tubes
2.The ABG reuslt above during admission revealed:
(0/1 Point)
respiratory acidosis
respiratory alkalosis
metabolic acidosis
metabolic alkalosis
3.The client's wife arrives on the unit 6 hours after her husband's accident,.
explaining that she has been out of town. She is distraught because she was not
with her husband when he needed her. The most appropriate initial nursing
intervention for her would be to:
(1/1 Point)
allow her to verbalize her feelings & concerns
describe her husband's medical treatment since admission
explain the nature of the injury and reassure her that husband's condition is stable
reassure her that the important fact is that she is here now
4.Twelve hours after the client's chest tube is removed, his ABG values include
PaO2 90 mm Hg. The nurse should interpret this value as indicating that:
(-/1 Point)
the client needs additional oxygen
the client should be encouraged to cough and deep breathe
the client's physician should be notified immediately
the client's response is adequate
5.pH 7.28; PaO2 50mm Hg; PaCO2 80 mmHg; HCO3 32 mEq/L
The nurse would interpret these ABG values as indicating:

(0/1 Point)
metabolic acidosis
metabolic alkalosis
respiratory acidosis
respiratory alkalosis
6.From the client's PaCO2 level, the nurse could safely conclude that the client is:
(1/1 Point)
hypoxemic
hypoventilating
hyperventilating
using oxygen tyherapy
7.From the client's PaO2 level, the nurse could safely conclude that the:
(0/1 Point)
client is hypoxic
oxygen level is low but poses no risk for the client
client's PaO2 level is within normal range
client requires oxygen therapy with very low oxygen concentrations
8.Based on the ABG values, the nurse would anticipate that the client will require
(0/1 Point)
more frequent percussion and postural drainage
increased aminophylline and corticosteroid doses
intensive teaching to facilitate pursed-lip breathing
endotracheal intubation and mechanical ventilation
9.The NCP for this client should include close monitoring for which of the
following signs and symptoms?
(0/1 Point)
cyanosis and restlessness
flushed skin & lethargy
weakness & irritability
anxiety & fever
10.During postural drainage, movement of secretions from the lower respiratory
tract to the upper respiratory tract occurs due to:
(1/1 Point)
friction between the cilia
the force of gravity
the sweeping motion of cilia
involuntary muscle contractions
11.Client's with COPD maybe bedridden at home & get little exercise. Which of
the following is a normal physiologic reaction to prolonged periods of bedrest &
inactivity?
(0/1 Point)
increased sodium retention
increased calcium excretion
increased insulin utilization
increased RBC production
12.Which of the following statements contains one of the basic rules to follow
when caring for a client with a chest tube & water seal drainage system?
(1/1 Point)
Ensure that the air vent on the water-seal drainage system is capped when the suction is off
Strip the chest & drainage tubes at least every 4 hours if excessive bleeding occurs
that the collection & suction bottles are at the client's chest level at all times
Ensure that the collection & suction bottles are below the client's chest level at all times
13.In an underwater-seal drainage system, cessation of fluid fluctuation in the
chest and drainage tubes generally means that the
(1/1 Point)
lung has fully expanded
lung has collapsed
chest tube is in the pleural space
mediastinal space has decreased
14.The nurse observes a constant gentle bubbling in the water-seal bottle of an
underwater-seal chest drainage system. This observation should prompt the
nurse to
(0/1 Point)
continue monitoring as usual; this a normal observation
check the connectors between the chest & drainage tubes and where the drainage tube enters
the collection bottle
decrease the suction to 15 cm H20 or less & continue observing the system for changes in
bubbling over the next several hours
drain half the water from the underwater-seal chamber
15.Which of the following findings would suggest pneumothorax in a trauma
victim
(1/1 Point)
pronounced crackles
inspiratory wheezing
dullness on percussion
absent breath sounds
16.Oxygen toxicity results from oxygen concentrations above
(0/1 Point)
21%
24%
40%
60%
17.The client undergoes surgery to repair lung injuries. Postoperative orders
include the transfusion of one units of packed red cells at a rate of 60ml/hour.
Approximately how long would this transfusion take?
(1/1 Point)
2 hours
4 hours
6 hours
8 hours
18.The primary reason for infusing blood at a rate of 60ml/hour is to help
prevent:
(1/1 Point)
emboli formation
pulmonary edema
RBC hemolysis
allergic reaction
19.Which of the following items should be readily available at the bedside of a
client with a chest tube in place?
(0/1 Point)
A tracheostomy tray
Another sterile chest tube
rubber-capped hemostats
a spirometer
20.Which of the following would be a priority nursing diagnosis category for a
cleint with ARDS?
(1/1 Point)
Ineffective breathing pattern
pain
Altered Health Maintenance
High Risk for Infection

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1.On admission the client's ABG values were pH 7.

20, PaO2 64 mmHg, PaCO2 60

The nurse would interpret these ABG values as indicating:

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