Question

Which expected outcome is most appropriately applied to a patient with a nursing diagnosis of Impaired gas exchange?

a.

The patient will have a decrease in cyanosis within 2 hours.

b.

The patient will be maintained in an upright sitting position.

c.

The patient’s pulse oximetry readings will be 95% or greater.

d.

The patient respirations will be quiet and of normal depth.

Answer 1

Correct Answer: D - the patient respiration will be quiet and of normal depth

Explanation:

Impaired gas exchange means excess or deficit in oxygenation and/ / or carbon dioxide elimination at the alveolar-capillary membrane.

1. Gas exchange is an important function of the lungs
2. The body requires oxygen for survival and energy production.
3. Carbon dioxide is produced during ATP synthesis.
4. The blood is a medium for the transport of both gases.
5. At the level of the lung, the carbon dioxide is removed from the blood into the alveoli and oxygen is transport from the alveoli to the pulmonary capillaries.

The expected outcomes in case of impaired gas exchange:

1. Maintenance of optimal gas exchange:
   1. Stable mental status
   2. Unlabored breathing with a respiratory rate of 12 - 20 per minute.
   3. The balanced depth of respiration.
   4. Pulse oximetry within a normal range.
   5. Normal heart rate
2. The patient is able to maintain clear lungs and there is no evidence of respiratory distress.
3. The patient verbalizes the understanding of oxygen and other intervention.
4. The patient participates in the procedures to maintain oxygenation.

Incorrect answers

Option A:

1. a decrease in cyanosis over 2 hours is not an expected outcome of impaired gas exchange.
2. Cyanosis is a late sign of respiratory failure.
3. By the time cyanosis develops, respiratory failure is in its advanced stage.
4. It is therefore, not a reliable sign.

Option B:

1. This is not an expected outcome for impaired gas exchange.
2. A patient who is in respiratory distress prefers to sit upright.
3. This position is called a tripod position.
4. In this position, the accessory respiratory muscle can function optimally.
5. Therefore, sitting upright is a sign of impaired gas exchange and not an expected outcome.

Option C:

1. A pulse oximeter reading more than 90% is considered normal.
2. When the partial pressure of oxygen in the blood is more than 60 mmHg, the pulse oximetry saturation is more than 90%