A patient has a diagnosis of Impaired Gas Exchange. Which assessment finding shows that the interventions have been effective?

The patient's Spo2 is 97% on 2L NC

The patient appears comfortable

The patient is coughing up copious white sputum

The patient is able to move out of bed without difficulty

Answer and Explanation

The Correct Answer is A

A. The patient's Spo2 is 97% on 2L NC:

This assessment finding indicates that the patient's oxygen saturation level (SpO2) is 97% while receiving 2 liters per minute of oxygen via nasal cannula. Oxygen saturation is a measure of the percentage of hemoglobin saturated with oxygen in the blood. A SpO2 level of 97% suggests adequate oxygenation, which is essential for effective gas exchange. Therefore, if the patient's SpO2 is within the target range on the prescribed oxygen therapy, it indicates that the interventions aimed at improving gas exchange have been effective.

B. The patient appears comfortable:

While patient comfort is important, it is not a direct indicator of effective gas exchange. A patient may appear comfortable for various reasons, such as pain relief, proper positioning, or emotional support, but this does not necessarily reflect improved gas exchange. Therefore, while comfort is an important aspect of nursing care, it is not specifically indicative of the effectiveness of interventions for impaired gas exchange.

C. The patient is coughing up copious white sputum:

The presence of copious white sputum does not directly indicate improved gas exchange. White sputum may suggest various conditions, such as respiratory tract infections or inflammation, but it does not provide direct information about gas exchange efficiency. Effective gas exchange involves the exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, which cannot be assessed solely based on sputum production.

D. The patient is able to move out of bed without difficulty:

The ability to move out of bed without difficulty may indicate improved overall physical function or mobility, but it does not specifically reflect improved gas exchange. Gas exchange primarily involves the transfer of oxygen from the alveoli into the bloodstream and the removal of carbon dioxide from the bloodstream into the alveoli for exhalation. While improved gas exchange may lead to enhanced physical endurance and reduced dyspnea, the ability to move out of bed without difficulty is not a direct measure of gas exchange efficiency.

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Correct Answer is ["A","B","D"]

Explanation

A. Dyspnea: Dyspneais a hallmark symptom of emphysema. As lung function deteriorates, the client experiences difficulty breathing, especially during exertion, due to reduced gas exchange and air trapping in the lungs.

B. Barrel chest:A barrel chest is a common finding in emphysema due to hyperinflation of the lungs over time. This causes the chest to become rounded and expands the anterior-posterior diameter of the thorax.

C. Clubbing of the fingers: Clubbing of the fingers is not a typical finding in emphysema or COPD. It is more commonly associated with conditions like lung cancer, cystic fibrosis, or congenital heart disease, where chronic severe hypoxia is present.

D. Shallow respirations:Clients with emphysema often exhibit shallow respirations as their lung elasticity decreases, making it difficult to fully exhale. As a result, breathing may become more rapid and shallow to compensate for poor oxygen exchange.

E. Bradycardia: Bradycardiais not typically associated with emphysema. Instead, clients with chronic respiratory conditions like emphysema may experience tachycardiaas the body tries to compensate for low oxygen levels.

A. Constipation B. Nausea C. Headache D. Hypotension

Correct Answer is C

Explanation

A. Constipation

Constipation is not typically associated with obstructive sleep apnea. However, sleep disturbances and certain medications used to manage OSA may indirectly contribute to constipation in some cases.

B. Nausea

Nausea is not a common symptom of obstructive sleep apnea. While sleep disturbances may affect gastrointestinal function in some individuals, nausea is not a typical manifestation of OSA.

C. Headache

One of the common findings associated with obstructive sleep apnea (OSA) is headache. This occurs due to the repeated episodes of apnea (cessation of breathing) during sleep, which leads to intermittent hypoxia (low oxygen levels) and subsequent cerebral vasodilation. The vasodilation can trigger headaches, often described as morning headaches, upon waking up. These headaches are typically frontal and may be accompanied by other symptoms such as fatigue and irritability.

D. Hypotension

Hypotension (low blood pressure) is not a typical finding in obstructive sleep apnea. In fact, individuals with OSA are more likely to have hypertension (high blood pressure) due to the effects of repeated apnea episodes on the cardiovascular system, such as increased sympathetic activity and arterial stiffness.

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A patient has a diagnosis of Impaired Gas Exchange. Which assessment finding shows that the interventions have been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is collecting data on a client who has obstructive sleep apnea. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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