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The pulse oximetry for a patient with right lower

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4.The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, aweak cough effort, and complains of fatigue. Which action is best for the nurse to take?a.Position the patient on the right side.b.Place a humidifier in the patient’s room.c.Assist the patient with staged coughing.d.Schedule a 2-hour rest period for the patient.ANS:CThe patient’s assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-
N418 Final All Book TQ85hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretionscan be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directedmore toward the more poorly ventilated lung.DIF:Cognitive Level: Application REF:1754-1755TOP:Nursing Process: ImplementationMSC:NCLEX: Physiological Integrity5.When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioneda.on the left side.b.on the right side.c.in the tripod position.d.in the high-Fowler’s position.ANS:BThe patient should be positioned with the “good” lung in the dependent position to improve the match between ventilation andperfusion. The obese patient’s abdomen will limit respiratory excursion when sitting in the high-Fowler’s or tripod positions.DIF:Cognitive Level: Application REF:1754-1755TOP:Nursing Process: ImplementationMSC:NCLEX: Physiological Integrity6.When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern tothe nurse?a.The patient is somnolent.b.The patient’s SpO2is 90%.c.The patient complains of weakness.d.The patient’s blood pressure is 162/94.ANS:AIncreasing somnolence will decrease the patient’s respiratory rate and further increase the PaCO2and respiratory failure. Rapid actionis needed to prevent respiratory arrest. An SpO2of 90%, weakness, and elevated blood pressure all require ongoing monitoring but arenot indicators of possible impending respiratory arrest.DIF:Cognitive Level: Application REF:1751TOP:Nursing Process: Assessment MSC:NCLEX: Physiological Integrity

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Term
Winter
Professor
N/A
Tags
pulmonary artery

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