a client with chronic obstructive pulmonary disease copd presented with shortness of breath oxygen therapy was started at 2 litersminute via nasal can
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Nursing Elites

HESI LPN

Medical Surgical Assignment Exam HESI

1. A client with chronic obstructive pulmonary disease (COPD) presented with shortness of breath. Oxygen therapy was started at 2 liters/minute via nasal cannula. The arterial blood gases (ABGs) after treatment were pH 7.36, PaO2 52, PaCO2 59, HCO3 33. Which statement describes the most likely cause of the simultaneous increase in both PaO2 and PaCO2?

Correct answer: B

Rationale: Oxygen therapy can reduce the hypoxic drive in COPD patients, leading to increased PaCO2 levels while improving oxygenation (PaO2). In this case, the increase in PaO2 and PaCO2 is due to the reduction of the hypoxic drive by the supplemental oxygen. Choice A is incorrect because hyperventilation would lead to decreased PaCO2. Choice C is incorrect as the ABG values do not indicate respiratory alkalosis. Choice D is incorrect as the ABG values do not support metabolic acidosis.

2. While assisting a female client to the toilet, the client begins to have a seizure, and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Correct answer: A

Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.

3. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

4. How are type IV hypersensitivity reactions different from all other types (I, II, or III) of hypersensitivity reactions?

Correct answer: B

Rationale: Type IV hypersensitivity reactions are mediated by T cells and cytokine release, leading to delayed reactions, unlike types I, II, and III, which involve antibodies. Choice A is incorrect because type IV reactions do not involve antigen-antibody complexes. Choice C is incorrect as type IV reactions do not result in immediate allergic reactions. Choice D is incorrect as type IV reactions are not the least severe form of hypersensitivity; in fact, they are known to cause significant tissue damage and inflammation.

5. A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question?

Correct answer: D

Rationale: With a CD4+ T cell count of 200 cells/microliter, the client's immune system is severely compromised, leading to opportunistic infections.

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