CCC 1 - Gas Exchange

A nurse is assessing a client for impaired gas exchange. Which assessment finding is the highest priority?

Cyanosis and confusion

The nurse is caring for a pediatric client who becomes restless and develops tachycardia and tachypnea. What should the nurse suspect?

Early Hypoxia

Which finding is considered a late manifestation of hypoxia in a pediatric client?

Bradycardia

A child's oxygen saturation is 84%. What is the nurse's priority action?

Recognize this as life-threatening hypoxemia and intervene immediately

Which assessment finding indicates increased work of breathing in an infant? Select all that apply

nasal flaring, retractions, grunting, cyanosis

The nurse is caring for an infant with nasal congestion. Why is this finding especially concerning?

Infants are obligate nose breathers until approximately 3 months of age.

A nurse observes an infant having an occasional respiratory pause lasting 8 seconds. What is the appropriate interpretation?

Brief pauses of less than 10–15 seconds can be normal in infants.

Which infant has the greatest risk for impaired gas exchange?

A premature infant born at 30 weeks' gestation

What is the primary function of surfactant?

Prevent alveolar collapse after exhalation.

A nurse is caring for a client with COPD who has difficulty breathing. Which position should the nurse use to promote ventilation?

Upright or tripod position.

Which nursing intervention is the priority for a client experiencing respiratory distress?

Maintain airway patency and assess oxygenation.

A client has thick respiratory secretions. Which intervention should the nurse include in the plan of care?

Encourage adequate fluid intake if not contraindicated.

Which interventions help promote gas exchange? Select all that apply.

elevating the head of the bed, coughing and deep breathing, incentive spirometry, adequate fluid intake

A postoperative client is at risk for decreased gas exchange. Which intervention should the nurse prioritize?

Encourage incentive spirometry.

What is the primary purpose of an incentive spirometer?

Promote lung expansion.

A nurse performs chest physiotherapy on a client with excessive respiratory secretions. What is the purpose of this intervention?

Break up and mobilize mucus.

A client with respiratory distress assumes a tripod position. The nurse understands that this position is used to:

Improve the client's ability to breathe.

Which finding is most concerning in a client with suspected hypoxia?

Cyanosis with bradycardia

Which statement correctly describes hypoxia?

Insufficient oxygen reaching the cells.

Which statement correctly describes hypoxemia?

Reduced oxygenation of arterial blood.

Which condition refers to a total lack of oxygen in body tissues?

Anoxia.

A client has insufficient oxygen delivered to tissues, resulting in cellular injury. Which condition is the nurse identifying?

Ischemia.

Which clients are at increased risk for decreased gas exchange? Select all that apply.

client with asthma, client with COPD, client with cystic fibrosis, client with prolonged immobility, client with spinal cord injury

Which environmental exposure increases a client's risk for impaired gas exchange? Select all that apply.

smoking, secondhand smoke, dust, chemicals, pollutants

Why are older adults at increased risk for decreased gas exchange? Select all that apply.

loss of alveolar elasticity, weaker respiratory muscles, weaker cough

A nurse is assessing a client for respiratory problems. Which information should be included in the health history? Select all that apply.

smoking history, secondhand smoke, history of asthma or COPD, environmental chemical exposure, previous respiratory illnesses

Which assessment finding should cause the nurse to suspect respiratory distress?

Nasal flaring and retractions.

The nurse is reviewing ABG results. Which pH value is within the expected range?

7.40

Which arterial blood gas result is within the expected range?

HCO₃⁻ 24 mEq/L

A client with severe respiratory difficulty assumes a tripod position. How should the nurse interpret this position?

The client is attempting to facilitate breathing

Why does an upright position help a client experiencing respiratory distress?

It promotes lung expansion and facilitates breathing

A client is experiencing difficulty breathing. Which nursing intervention should the nurse perform first?

Place the client upright

A client has decreased oxygenation of the arterial blood. Which term should the nurse document?

Hypoxemia

The nurse is caring for a client experiencing insufficient oxygen delivery to tissues that is resulting in cellular injury. Which condition does this describe?

Ischemia

A nurse is caring for a child who has respiratory distress. Which finding is the earliest indication of hypoxia?

Tachycardia

Which findings indicate early hypoxia in a pediatric client? Select all that apply.

restlessness, tachycardia, pallor, tachypnea

A child with respiratory distress initially has tachycardia and tachypnea. The child's condition worsens and the heart rate decreases. How should the nurse interpret this change?

The child is experiencing a late manifestation of hypoxia

The nurse is caring for a 2-month-old infant with nasal congestion. Why is this finding particularly concerning?

Infants are obligate nose breathers

The nurse assesses a healthy infant and notes occasional pauses in breathing lasting 8 seconds. What is the appropriate interpretation?

This is an expected respiratory pattern in infants

With ABG testing, what are normal pH ranges?

7.35-7.45

What is the normal range of Pao2?

80mm HG

What is the normal range for PaCo2?

35-45 mm HG

What is the normal range for HCO3?

22-26 meq/L

What is the normal range for Sao2?

94%

What does RBC do in complete blood count?

oxygen carrying capacity

What is hemoglobin (hb) responsible for in complete blood count?

each RBC carries hb

What are the ranges of WBC in the complete blood count?

4,500-10,500/mm³

What are the ranges of platelets in complete blood count?

140,000-400,000/mm³