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 B

Explanation

A. Prepare the client for endotracheal suctioning.

Endotracheal suctioning is a procedure used to clear secretions from the airway, which may be necessary in cases of respiratory distress. However, it is not the first action to take in this scenario. Before proceeding with suctioning, the nurse should first assess the client's respiratory status and implement interventions to improve ventilation and oxygenation.

B. Elevate the head of the bed.

This is the correct action to take first. Elevating the head of the bed helps improve the client's respiratory mechanics by allowing better lung expansion and reducing the work of breathing. It also helps alleviate symptoms of respiratory distress. This intervention should be implemented immediately to optimize the client's breathing.

C. Request a chest x-ray.

While a chest x-ray may provide valuable information about the client's respiratory status, it is not the first action to take in this acute situation. Chest x-rays require time to be performed and interpreted, which may delay necessary interventions to address the client's immediate respiratory distress.

D. Obtain a sputum culture.

Obtaining a sputum culture may be indicated to identify the underlying cause of respiratory distress, such as infection. However, it is not the first action to take when the client is experiencing acute respiratory distress. The priority is to implement interventions to improve ventilation and oxygenation to stabilize the client's condition.

A. Place tissue soiled with respiratory secretions in a paper bag for later disposal. B. Provide samples for sputum cultures every 6 weeks. C. Consume alcohol in moderation while taking antituberculosis medications. D. Wear a mask while out or around crowds of people.

Correct Answer is D

Explanation

A. Place tissue soiled with respiratory secretions in a paper bag for later disposal:

This instruction is not accurate or recommended for managing tissue soiled with respiratory secretions, particularly in the context of tuberculosis (TB) infection. TB is transmitted through the air via respiratory droplets, so proper disposal of contaminated materials is crucial to prevent the spread of the infection. Instead of placing tissue in a paper bag, it should be disposed of in a sealed plastic bag to minimize the risk of transmission. Additionally, individuals with TB should be instructed on proper respiratory hygiene practices, such as covering their mouth and nose with a tissue or their elbow when coughing or sneezing, to prevent the spread of infectious droplets.

B. Provide samples for sputum cultures every 6 weeks:

Sputum cultures are an essential component of monitoring and managing tuberculosis (TB) treatment. However, obtaining samples every 6 weeks is not frequent enough, especially during the initial phase of treatment. In the early stages of TB treatment, sputum cultures are typically obtained more frequently, often weekly or biweekly, to monitor the response to treatment, assess for drug resistance, and ensure treatment effectiveness. As treatment progresses and the patient's condition stabilizes, the frequency of sputum cultures may be adjusted based on clinical judgment and guidelines.

C. Consume alcohol in moderation while taking antituberculosis medications:

Alcohol consumption is generally discouraged while taking antituberculosis medications. Some antituberculosis drugs, such as isoniazid and rifampin, can interact with alcohol and cause adverse effects, such as liver toxicity or drug metabolism issues. Therefore, individuals undergoing treatment for tuberculosis should be advised to abstain from alcohol consumption or limit it to a minimum to avoid potential complications. Providing instructions on alcohol consumption is an important aspect of tuberculosis management and medication adherence.

D. Wear a mask while out or around crowds of people:

This instruction is crucial for individuals with pulmonary tuberculosis to prevent the spread of the infection to others. Tuberculosis is transmitted through the air via respiratory droplets, particularly when an infected person coughs, sneezes, or talks. Wearing a mask while out or in crowded settings helps reduce the risk of transmitting infectious droplets to others and is an important infection control measure. It is especially important during the early stages of treatment when the individual is still infectious and shedding bacteria. Proper mask use, along with other respiratory hygiene practices, can help protect both the individual with tuberculosis and those around them from the spread of infection.

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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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