Question

The nurse understands that a patient with pulmonary emphysema cannot exceed 2-3 L/min with supplemental nasal cannula oxygen therapy. Select the correct rationale below.

Answer 1

Correct Answers:

The person with emphysema chronically retains CO₂ and the medulla has self-adjusted. Excessive supplemental oxygen will knock out his/her hypoxic drive.

Rationale :

🫁 Clients with pulmonary emphysema may chronically retain carbon dioxide because damaged alveoli impair gas exchange.

🫁 Over time, the respiratory center becomes less sensitive to high CO₂ levels.

🫁 These clients may depend more on low oxygen levels, called the hypoxic drive, to stimulate breathing.

🫁 Giving excessive oxygen can reduce this drive and lead to hypoventilation.

🫁 Oxygen is usually administered cautiously, often around 2 to 3 L/min by nasal cannula, while monitoring respiratory status and oxygen saturation.

The person with emphysema normally breathes faster than healthy people. Excessive supplemental oxygen will cause tachycardia for this client.

🫁Tachycardia is not the main reason oxygen is limited in emphysema.

🫁The concern is suppression of the hypoxic respiratory drive.

The person with emphysema has chronically dilated bronchioles. Excessive supplemental oxygen will further dilate the airways which will lead to apnea.

🫁Excess oxygen does not cause apnea by dilating bronchioles.

🫁Apnea risk is related to decreased respiratory stimulation in chronic CO₂ retainers.

The person with emphysema has an overactive mucous production. Excessive supplemental oxygen will cause drying of secretions and mucous plugs.

🫁Dry secretions can occur with oxygen therapy, especially without humidification, but this is not the main rationale for limiting oxygen flow in emphysema.

🫁The priority concern is CO₂ retention and reduced respiratory drive.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Client experiencing hypoventilation and decreased breath sounds.

Rationale :

🚨 Hypoventilation means the client is not moving enough air to maintain adequate gas exchange.

🚨 Decreased breath sounds can indicate poor air movement, respiratory muscle fatigue, or impending respiratory failure.

🚨 This client is at greatest risk for airway compromise and may require immediate intubation to support ventilation.

🚨 Intubation protects the airway and allows assisted breathing when the client cannot ventilate effectively.

🚨 The nurse should prioritize airway and breathing because inadequate ventilation can quickly lead to hypoxemia, hypercapnia, and respiratory arrest.

Client with thick, purulent secretions, rhonchi, and rales.

🚨This client needs airway clearance, suctioning, hydration, and infection management, but the findings do not automatically indicate immediate intubation.

🚨Air movement is still present with adventitious sounds.

Client with an oxygen saturation of 97% and thin clear sputum.

🚨An oxygen saturation of 97% indicates adequate oxygenation.

🚨Thin clear sputum does not suggest severe airway obstruction or respiratory failure.

Client experiencing an acute asthma attack with adequate air movement.

🚨An acute asthma attack requires prompt treatment, but adequate air movement means ventilation is still occurring.

🚨Immediate intubation is more likely when breath sounds become diminished or silent.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Normal ABG

Rationale :

💎 The pH is 7.38, which is within the normal range of 7.35 to 7.45.

💎 The PaCO₂ is 39 mm Hg, which is normal and shows adequate ventilation.

💎 The HCO₃ is 24 mEq/L, which is normal and shows no metabolic imbalance.

💎 The PaO₂ is 99 mm Hg, which indicates normal oxygenation without hypoxemia.

💎 Because all values are within expected ranges, this ABG is interpreted as normal.

Respiratory alkalosis without hypoxemia

💎Respiratory alkalosis would show an elevated pH with a decreased PaCO₂.

💎This ABG has a normal pH and normal PaCO₂.

Respiratory acidosis without hypoxemia

💎Respiratory acidosis would show a low pH and elevated PaCO₂.

💎These findings are not present.

Respiratory acidosis with hypoxemia

💎This would require a low pH, elevated PaCO₂, and low PaO₂.

💎The client’s oxygenation and acid-base values are normal.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Respiratory alkalosis without hypoxemia

Rationale :

🔷 The pH is 7.49, which is elevated and indicates alkalosis.

🔷 The PaCO₂ is 31 mm Hg, which is low and shows the alkalosis is respiratory in origin.

🔷 A low PaCO₂ commonly occurs from hyperventilation, where the client blows off too much carbon dioxide.

🔷 The HCO₃ is 26 mEq/L, which is within the normal range and shows no primary metabolic cause.

🔷 The PaO₂ is 96 mm Hg, which is normal, so there is no hypoxemia.

Respiratory acidosis without hypoxemia

🔷Respiratory acidosis requires a low pH and elevated PaCO₂.

🔷This client has an elevated pH and decreased PaCO₂.

Respiratory alkalosis with hypoxemia

🔷The acid-base part is respiratory alkalosis, but the PaO₂ is normal.

🔷Hypoxemia would require a decreased PaO₂.

Respiratory acidosis with hypoxemia

🔷This is not respiratory acidosis because the pH is high and PaCO₂ is low.

🔷 The client also does not have hypoxemia because PaO₂ is 96 mm Hg.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Respiratory acidosis

Rationale :

🟣 The pH is 7.22, which is below normal and indicates acidosis.

🟣 The PaCO₂ is 50 mm Hg, which is elevated and identifies the cause as respiratory.

🟣 Respiratory acidosis occurs when the lungs cannot remove enough carbon dioxide.

🟣 The HCO₃ is 24 mEq/L, which is normal, showing there is no metabolic compensation yet.

🟣 This pattern is consistent with uncompensated respiratory acidosis, often caused by hypoventilation or impaired gas exchange.

Respiratory alkalosis

🟣Respiratory alkalosis would show an elevated pH and low PaCO₂.

🟣This client has a low pH and high PaCO₂.

Metabolic acidosis

🟣Metabolic acidosis would show a low pH with a decreased HCO₃.

🟣This client’s HCO₃ is normal.

Metabolic alkalosis

🟣Metabolic alkalosis would show a high pH with elevated HCO₃.

🟣The client has acidosis, not alkalosis.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Perform incentive spirometry every hour while awake.

Rationale :

🟢 Incentive spirometry helps expand the lungs and prevents alveolar collapse.

🟢 Rib fractures cause pain, which can make the client take shallow breaths and avoid coughing.

🟢 Shallow breathing increases the risk for atelectasis, especially after injury or surgery.

🟢 Using the incentive spirometer every hour while awake encourages deep breathing and improves ventilation.

🟢 The nurse should also teach splinting, coughing, deep breathing, and adequate pain control to support lung expansion.

Complete cast care every 8 hours.

🟢Cast care is unrelated to preventing atelectasis from rib fractures.

🟢The priority teaching should focus on lung expansion and deep breathing.

Take Oxycodone PO every 6 hours.

🟢Pain control can help the client breathe deeply, but opioids alone do not prevent atelectasis.

🟢Opioids can also depress respirations if not monitored carefully.

Perform proper hand hygiene at home.

🟢Hand hygiene helps reduce infection transmission.

🟢It does not directly prevent alveolar collapse from shallow breathing.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

"Engaging the child in daily exercises like yoga or walking can help break up the mucous."

Rationale :

🌟 Children with cystic fibrosis develop thick, sticky mucus that can obstruct the airways.

🌟 Daily physical activity helps mobilize secretions and supports better airway clearance.

🌟 Activities such as walking, yoga, swimming, or age-appropriate exercise can improve ventilation and mucus movement.

🌟 Exercise also supports endurance, respiratory muscle strength, and overall health.

🌟 This teaching is appropriate because airway clearance is a major part of long-term cystic fibrosis management.

“Bradycardia is an early indicator of a pneumothorax.”

🌟Bradycardia is not an early sign of pneumothorax.

🌟Early findings are more likely sudden chest pain, dyspnea, tachypnea, decreased breath sounds, and oxygen desaturation.

“A pigeon-shaped chest might become evident as the disease progresses.”

🌟Cystic fibrosis is commonly associated with a barrel chest as chronic air trapping progresses.

🌟Pigeon chest is not the classic expected chest change.

“Administer a bronchodilator to the child after chest percussion therapy.”

🌟Bronchodilators are usually given before airway clearance therapy to open the airways.

🌟This helps chest percussion and coughing remove mucus more effectively.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Hypokalemia

Rationale :

🟡 The EKG shows classic hypokalemia findings, including ST depression, shallow T waves, and prominent U waves.

🟡 Low potassium delays ventricular repolarization, which causes visible U waves after the T wave.

🟡 Hypokalemia increases the risk for cardiac dysrhythmias, especially when potassium levels continue to fall.

🟡 The nurse should assess for muscle weakness, fatigue, leg cramps, constipation, and irregular pulse.

🟡 Potassium replacement and cardiac monitoring may be required depending on the severity and provider orders.

Hyperkalemia

🟡Hyperkalemia usually causes tall peaked T waves, widened QRS complexes, and possible conduction delays.

🟡 The EKG shown has prominent U waves, which is more consistent with hypokalemia.

Hypermagnesemia

🟡Hypermagnesemia commonly causes hypotension, decreased reflexes, muscle weakness, bradycardia, and respiratory depression.

🟡It is not typically identified by prominent U waves on EKG.

Normal Kalemia

🟡Normal potassium levels should not produce marked ST depression, shallow T waves, and prominent U waves.

🟡These findings indicate an electrolyte abnormality rather than a normal tracing.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Hydrochlorothiazide

Rationale :

💧 Hydrochlorothiazide is a thiazide diuretic that helps remove excess fluid by increasing urine output.

💧 In fluid volume excess, the goal is to decrease circulating fluid volume and reduce edema or congestion.

💧 This medication promotes sodium and water excretion through the kidneys.

💧 The nurse should monitor blood pressure, intake and output, daily weight, and electrolytes, especially potassium.

💧 Diuretic therapy helps relieve manifestations of fluid overload such as swelling, hypertension, and increased workload on the heart.

Calcium gluconate

💧Calcium gluconate is used to treat hypocalcemia or stabilize the heart in severe hyperkalemia.

💧It does not treat fluid volume excess.

Pamidronate disodium (Aredia)

💧Pamidronate is used to treat hypercalcemia, especially related to malignancy.

💧It does not remove excess body fluid.

Potassium chloride

💧Potassium chloride is used to treat or prevent hypokalemia.

💧It does not promote fluid removal and could be unsafe if potassium is already elevated.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Notify the HCP before administering the dose.

Rationale :

🟡 A potassium level of 2.8 mEq/L indicates significant hypokalemia.

🟡 Furosemide is a loop diuretic that can cause further potassium loss through urine.

🟡 Giving furosemide when potassium is already low can increase the risk for dangerous dysrhythmias.

🟡 The nurse should notify the healthcare provider before administering the medication so potassium replacement or medication adjustment can be prescribed.

🟡 The client should also be monitored for weakness, muscle cramps, irregular pulse, and EKG changes such as U waves.

Give the patient half of the ordered dose.

🟡The nurse should not independently change the prescribed dose.

🟡Dose adjustment requires a provider order.

Hold the medication and document the potassium level.

🟡The medication should not be given, but the nurse must also notify the provider because the abnormal potassium requires intervention.

🟡Documentation alone is not enough.

Administer the medication as ordered.

🟡Administering furosemide with potassium at 2.8 mEq/L can worsen hypokalemia.

🟡This increases the risk for cardiac complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
The nurse understands that a patient with pulmonary emphysema cannot exceed 2-3 L/min with supplemental nasal cannula oxygen therapy. Select the correct rationale below.

2 :
The nurse recognizes that which of the following patients is in the greatest need of immediate intubation?

3 :
Interpret the following ABG laboratory values: pH 7.38, paO2-99, paCO2-39, HCO3-24.

4 :
Interpret the following ABG laboratory values: pH 7.49, paO2-96, paCO2-31, HCO3-26.

5 :
A nurse is caring for a client whose arterial blood gas results show: pH: 7.22, PaCO2: 50 mm Hg, HCO3: 24 mEq/L. The nurse identifies which of the following acid-base conditions the client is experiencing.

6 :
Which of the following patient discharge teaching will decrease the risk of atelectasis in a patient with rib fractures?

7 :
A nurse is reinforcing teaching with the parents of a school-age child with cystic fibrosis. Which of the following statements will the nurse make?

8 :
Identify the condition indicated by the EKG.

9 :
The nurse is caring for a patient with fluid volume excess. What medication will the nurse administer?

10 :
The nurse is preparing to administer furosemide (Lasix) and notes the patient's potassium level is 2.8 mEq/L. How will the nurse proceed?

QLexNursing

1 : The nurse understands that a patient with pulmonary emphysema cannot exceed 2-3 L/min with supplemental nasal cannula oxygen therapy. Select the correct rationale below.

2 : The nurse recognizes that which of the following patients is in the greatest need of immediate intubation?

3 : Interpret the following ABG laboratory values: pH 7.38, paO2-99, paCO2-39, HCO3-24.

4 : Interpret the following ABG laboratory values: pH 7.49, paO2-96, paCO2-31, HCO3-26.

5 : A nurse is caring for a client whose arterial blood gas results show: pH: 7.22, PaCO2: 50 mm Hg, HCO3: 24 mEq/L. The nurse identifies which of the following acid-base conditions the client is experiencing.

6 : Which of the following patient discharge teaching will decrease the risk of atelectasis in a patient with rib fractures?

7 : A nurse is reinforcing teaching with the parents of a school-age child with cystic fibrosis. Which of the following statements will the nurse make?

8 : Identify the condition indicated by the EKG.

9 : The nurse is caring for a patient with fluid volume excess. What medication will the nurse administer?

10 : The nurse is preparing to administer furosemide (Lasix) and notes the patient's potassium level is 2.8 mEq/L. How will the nurse proceed?

1 :
The nurse understands that a patient with pulmonary emphysema cannot exceed 2-3 L/min with supplemental nasal cannula oxygen therapy. Select the correct rationale below.

2 :
The nurse recognizes that which of the following patients is in the greatest need of immediate intubation?

3 :
Interpret the following ABG laboratory values: pH 7.38, paO2-99, paCO2-39, HCO3-24.

4 :
Interpret the following ABG laboratory values: pH 7.49, paO2-96, paCO2-31, HCO3-26.

5 :
A nurse is caring for a client whose arterial blood gas results show: pH: 7.22, PaCO2: 50 mm Hg, HCO3: 24 mEq/L. The nurse identifies which of the following acid-base conditions the client is experiencing.

6 :
Which of the following patient discharge teaching will decrease the risk of atelectasis in a patient with rib fractures?

7 :
A nurse is reinforcing teaching with the parents of a school-age child with cystic fibrosis. Which of the following statements will the nurse make?

8 :
Identify the condition indicated by the EKG.

9 :
The nurse is caring for a patient with fluid volume excess. What medication will the nurse administer?

10 :
The nurse is preparing to administer furosemide (Lasix) and notes the patient's potassium level is 2.8 mEq/L. How will the nurse proceed?