A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?- Nurselytic

Question 1 of 5

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?

A. The patients calcium will rise dramatically due to pituitary stimulation. B. Oxygen will increase the patients intracranial pressure and create confusion. C. Oxygen may cause the patient to hyperventilate and become acidotic. D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Correct Answer: D

Rationale: The correct answer is D: Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. In patients with chronic emphysema, their respiratory drive is often triggered by low oxygen levels rather than high carbon dioxide levels. Administering supplemental oxygen can suppress their respiratory drive, leading to carbon dioxide retention (carbon dioxide narcosis) and worsening hypoxemia. This phenomenon is known as "hypoxic drive." Choice A is incorrect because administering oxygen does not lead to a dramatic rise in calcium levels due to pituitary stimulation. Choice B is incorrect because administering oxygen does not typically increase intracranial pressure or cause confusion. Choice C is incorrect because administering oxygen does not directly cause hyperventilation and acidosis in this scenario.

Question 2 of 5

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

A. Administer a sublingual nitroglycerin tablet B. Prepare to assist with chest tube insertion. C. . Place a sterile dressing over the IV site D. Re-position the client into the Trendelenburg position.

Correct Answer: B

Rationale: The correct answer is B: Prepare to assist with chest tube insertion. Chest pain and difficulty breathing after subclavian central venous catheter insertion could indicate a pneumothorax, a potential complication. Chest tube insertion is indicated to help re-expand the lung and relieve the pressure in the thoracic cavity. This intervention takes priority over the other options because it addresses the potential life-threatening complication of a pneumothorax. Administering nitroglycerin (choice A) is not indicated for chest pain in this scenario. Placing a sterile dressing over the IV site (choice C) is not appropriate for managing chest pain and difficulty breathing. Re-positioning the client into the Trendelenburg position (choice D) is not effective in addressing a pneumothorax and may worsen the client's condition.

Question 3 of 5

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)

A. A 36-year-old who is malnourished B. A 42-year-old with uncontrolled diabetes C. A 76-year-old who is prescribed antacids D. 50-year-old with hyperparathyroidism

Correct Answer: C

Rationale: The correct answer is C because antacids contain aluminum or magnesium, which can bind with phosphorus and decrease its absorption, leading to hypophosphatemia. Malnourishment (choice A) can cause hypophosphatemia due to inadequate intake, uncontrolled diabetes (choice B) is associated with hyperphosphatemia, and hyperparathyroidism (choice D) can lead to hyperphosphatemia due to increased calcium levels.

Question 4 of 5

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?

A. Depth of respirations B. Bowel sounds C. Grip strength D. Electrocardiography

Correct Answer: A

Rationale: The correct assessment for the nurse to complete first is A: Depth of respirations. Potassium and magnesium levels are crucial electrolytes that can affect cardiac function. Hypokalemia (low potassium) and hypomagnesemia (low magnesium) can lead to cardiac dysrhythmias. Checking the depth of respirations can provide valuable information on the client's respiratory status and potential respiratory distress due to electrolyte imbalances. This assessment takes precedence as addressing respiratory issues promptly is essential to prevent further complications. Assessing bowel sounds (B), grip strength (C), and electrocardiography (D) are important but not as immediate as assessing respiratory status in this scenario.

Question 5 of 5

1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?

A. Lower the extremity below the level of the heart. B. Apply warm compresses to the extremity. C. Tap the skin lightly and avoid slapping. D. Place a washcloth between the skin and tourniquet

Correct Answer: D

Rationale: The correct answer is D: Place a washcloth between the skin and tourniquet. This step helps protect the client's skin by providing a barrier between the tourniquet and the skin, reducing the risk of skin irritation or damage. Lowering the extremity below the heart (A) can increase venous pressure and make it harder to insert the catheter. Warm compresses (B) can dilate blood vessels and increase the risk of bruising. Tapping the skin lightly (C) can irritate the skin and is unnecessary for skin protection.

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Nurselytic

ATI RN