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a. “It’s common for clients with uncomfortable procedures such as nasogastric tubes to have ahigher rate of breathing”b. “The client may have a metabolic alkalosis due to the NG suctioning and the increasedrespiratory rate is acompensatory mechanism”c. “Whenever a client develops a respiratory acid-base problem, increasing the respiratory ratehelps correct the problem”d. “The client is hyperventilating because of anxiety and we will have to stay alert fordevelopment of a respiratory acidosis”ANSWER: BNasogastric suctioning can result in a decrease in acid components and a metabolic alkalosis.The client’s increase inrate and depth of ventilation is an attempt to compensate by blowing off CO2. The first responsemay be true butdoes not address all the components of the question. The third and fourth answers areinaccurate.Reference: Brunner and Suddarth’s Medical Surgical Nursing 12th edition68. When a client has arterial blood gasses drawn, the nurse most needs to assure that which ofthe following actionsare carried out?a. The client is instructed to lie down and remain lying down for at least 20 minutesb. The client's blood pressure is taken every five minutes for fifteen minutesc. Firm pressure is applied to the site for at least five minutesd. The blood sample is kept in a cool location until the laboratory runs the testsANSWER: CAfter the arterial blood sample has been drawn, firm pressure must be applied to the site for 5minutes to preventbleeding into surrounding tissues.Reference: Potter and Perry. Fundamentals of Nursing 6th edition
69. A client has intravenous therapy for the administration of antibiotics and is stating that the“IV site hurts and isswollen.” Which of the following information assessed on the client indicates the presence ofphlebitis, as opposed toinfiltration?a. Intensity of the painc. Amount of subcutaneous edema
b. Warmth of integument surrounding the IV sited. Skin discoloration of a bruised natureANSWER: BSigns of phlebitis may include increased temperature over the vein, erythema, pain and edema.With phlebitis, thearea is warm to the touch; with infiltration, the area is cool to the touch. Option A: The intensityof pain is not adifferentiating factor between phlebitis and infiltration. Pain may occur with both. Option C: Theamount ofsubcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema mayoccur with both.Option D: Skin discoloration of a bruised nature is not the best way to differentiate phlebitis frominfiltration. Withphlebitis, the area is typically reddened. With infiltration, the area is typically pale.Reference: Potter and Perry. Fundamentals of Nursing 6th edition page 118970. The nurse explains that when oxygen is directed out of the arteries and into the capillaries,this process is:a. Active transportb. Diffusionc. Filtrationd. OsmosisANSWER: BDiffusion is the movement from areas of higher concentration to areas of lower concentration.

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