The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
inspecting:
A. Chest excursion
B. Spinal
... [Show More] curvatures
C. The respiratory pattern
D. The fingernail and its base
D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in
the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied
by an increase in the depth, bulk, and sponginess of the end of the finger.
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases
to be drawn. Which of the following is the minimum length of time the nurse should plan to hold
pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the puncture
site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under
higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is
insufficient.
3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a
nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal.
A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal
fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the
presence of CSF.
4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority
assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
A. Airway patency Remember ABCs with prioritization. Airway patency is always the highest priority and
is essential for a patient undergoing surgery surrounding the upper respiratory system. [Show Less]