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 C

Explanation

A. Rest in a supine position.

This option is not recommended for improving gas exchange in emphysema. Resting in a supine position can lead to decreased lung expansion and increased dyspnea in individuals with emphysema. Optimal lung expansion is crucial for efficient gas exchange, and certain positions, such as sitting upright or using pillows to support the head and chest, are preferred to facilitate breathing.

B. Consume a low-protein diet.

A low-protein diet is not directly related to improving gas exchange in emphysema. In fact, adequate protein intake is important for maintaining overall health and supporting respiratory muscle function. Protein is necessary for tissue repair and maintaining muscle strength, including the respiratory muscles. Therefore, a balanced diet that includes adequate protein intake is recommended for individuals with emphysema.

C. Breathe in through her nose and out through pursed lips.

This is the correct choice. Breathing in through the nose and out through pursed lips helps to create positive pressure in the airways during exhalation. This positive pressure helps to keep the airways open, prevents premature collapse of the air sacs (alveoli), and facilitates more effective gas exchange. It also slows down the rate of breathing, reduces the work of breathing, and can alleviate shortness of breath (dyspnea) in individuals with emphysema.

D. Limit fluid intake throughout the day.

Limiting fluid intake throughout the day is not recommended for improving gas exchange in emphysema. Adequate hydration is important for thinning respiratory secretions, which can make it easier to clear mucus from the airways. Dehydration can worsen respiratory symptoms and increase the risk of complications. Therefore, maintaining adequate fluid intake is essential for individuals with emphysema.

A. Pigeon B. Funnel C. Kyphotic D. Barrel

Correct Answer is D

Explanation

A. Pigeon

A pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs, resulting in a pigeon-like appearance of the chest. This deformity is not typically associated with COPD.

B. Funnel

A funnel chest, also known as pectus excavatum, is a deformity of the chest characterized by a depression or concavity in the sternum, resulting in a funnel-like appearance of the chest. This deformity is not typically associated with COPD.

C. Kyphotic

Kyphosis refers to an exaggerated forward curvature of the thoracic spine, leading to a hunched or rounded upper back. While individuals with severe COPD may develop kyphosis due to chronic respiratory muscle fatigue and increased work of breathing, kyphotic curvature is not specific to COPD and can occur in other conditions as well.

D. Barrel

In COPD (Chronic Obstructive Pulmonary Disease), the client's chest may take on a barrel shape. This is characterized by an increase in the anterior-posterior diameter of the chest, resulting in a more rounded appearance similar to that of a barrel. This change in chest shape is due to hyperinflation of the lungs, which occurs as a result of air trapping and increased residual volume in the lungs, common in COPD.

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

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