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What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Potential Condition: Bleeding, Actions to Take: Observe surgical dressing, obtain blood cultures, Parameters to Monitor: Blood pressure, Patient’s performance of lung expansion exercises.

Potential Condition: Air leak, Actions to Take: Check the drainage system, Parameters to Monitor: Respiratory status, Chest tube drainage.

Potential Condition: Pulmonary edema.

Potential Condition: Pneumonia.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.

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Correct Answer is A

Explanation

Choice A rationale
In a client diagnosed with chronic obstructive pulmonary disease (COPD), an arterial blood gas (ABG) test would typically show an increased level of carbon dioxide (PaCO2)56. This is because COPD affects the ability of the lungs to expel carbon dioxide, leading to its buildup in the blood.
Choice B rationale
An increased pH is not typically seen in COPD. In fact, due to the increased carbon dioxide (which is acidic), the pH may be lower, indicating respiratory acidosis.
Choice C rationale
Decreased alveolar function is a characteristic of COPD, but it is not something that would be directly measured in an ABG test.
Choice D rationale
An increased arterial oxygen (PaO2) is not typically seen in COPD. In fact, due to the impaired gas exchange, PaO2 may be lower.

A. It decreases trapped oxygen in the alveoli. B. It promotes independent breathing efforts. C. It keeps the airways and small lung spaces open. D. It facilitates weaning off the mechanical ventilator.

Correct Answer is C

Explanation

Choice A rationale
PEEP does not decrease trapped oxygen in the alveoli. Instead, it helps to increase the volume of gas remaining in the lungs at the end of expiration, which can improve oxygenation.
Choice B rationale
PEEP does not directly promote independent breathing efforts. It is a mode of mechanical ventilation used to support a patient’s breathing.
Choice C rationale
PEEP keeps the airways and small lung spaces open by increasing the pressure in the lungs at the end of expiration. This can prevent alveolar collapse and improve oxygenation in patients with conditions like ARDS23.
Choice D rationale
While PEEP can be used in the process of weaning a patient off mechanical ventilation, its primary benefit is not facilitating weaning. It is used to improve oxygenation and prevent alveolar collapse.

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What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is analyzing arterial blood gas results for a client diagnosed with chronic obstructive pulmonary disease (COPD). What abnormal finding should the nurse anticipate?

Correct Answer is A

Explanation

A nurse is caring for a client diagnosed with adult respiratory distress syndrome (ARDS) and being treated with positive end expiratory pressure (PEEP). How does PEEP benefit the client?

Correct Answer is C

Explanation

What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

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