Nokea
A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess:
- A. Lung vibrations
- B. Vocal sounds
- C. Breath sounds
- D. Chest movements.
Correct Answer: D
Rationale: The correct answer is D: Chest movements. When checking respiratory status, observing chest movements, known as respiratory excursion, helps assess the depth and symmetry of breathing. This provides valuable information about lung expansion and function. Lung vibrations (A) are assessed by tactile fremitus, vocal sounds (B) by auscultating for voice sounds, and breath sounds (C) by listening for air movement in the lungs. However, these do not directly assess respiratory excursion.
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A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.
The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions shouldn't the nurse include in the teaching plan?
- A. Place contaminated tissues in sealable plastic bag.
- B. Take medications exactly as directed.
- C. Implement airborne precautions.
- D. Wash hands frequently.
Correct Answer: C
Rationale: The correct answer is C because TB is transmitted through droplet transmission, not airborne. The nurse should include hand hygiene (D) to prevent spread through contact, proper medication adherence (B) to treat TB effectively, and proper disposal of contaminated materials (A) to prevent spread through fomites. Implementing airborne precautions is not necessary for TB, as it does not remain suspended in the air for long periods.
During one circuit of blood from lungs to the tissue and back through the circulatory system the percentage of haemoglobin giving the oxygen is
- A. 50%
- B. 25%
- C. 75%
- D. 100%
Correct Answer: B
Rationale: The correct answer is B (25%). In the lungs, oxygen binds to hemoglobin to form oxyhemoglobin. This increases the oxygen saturation of hemoglobin to around 97-98%. As blood travels to the tissues, oxygen is released from hemoglobin to be used by the cells. By the time blood returns to the lungs, only about 25% of the hemoglobin is still carrying oxygen. This is known as the oxygen saturation curve. Choice A (50%) is incorrect because the percentage of hemoglobin carrying oxygen drops significantly as blood travels to the tissues. Choice C (75%) is incorrect because by the time blood returns to the lungs, more than 25% of the hemoglobin has already released its oxygen. Choice D (100%) is incorrect because not all hemoglobin molecules carry oxygen at the same time; it depends on the oxygen tension in the environment.
If his R = 0.8 how much will his arterial pO2 fall?
- A. 85mmHg
- B. 75mmHg
- C. 60mmHg
- D. 50mmHg
Correct Answer: D
Rationale: The correct answer is D (50mmHg). To calculate the fall in arterial pO2, we use the formula: Fall in pO2 = (Initial pO2) - (Initial pO2 x R). If R = 0.8, the fall in pO2 = (100mmHg) - (100mmHg x 0.8) = 100mmHg - 80mmHg = 20mmHg. Therefore, the arterial pO2 will fall by 20mmHg. Among the choices, D (50mmHg) is the closest to the calculated value of 20mmHg, making it the correct answer. Other choices (A, B, C) do not align with the calculated fall in pO2.
What is the name given to the respiratory ailment in which the bronchioles constrict severely?
- A. pleurisy
- B. emphysema
- C. bronchitis
- D. asthma
Correct Answer: D
Rationale: The correct answer is D: asthma. Asthma is a respiratory ailment characterized by severe constriction of the bronchioles due to inflammation and muscle contraction. This leads to difficulty breathing and wheezing. Pleurisy (A) is inflammation of the lining of the lungs, emphysema (B) is a long-term lung disease, and bronchitis (C) is inflammation of the bronchial tubes. Asthma specifically refers to the bronchioles constriction, making it the correct choice.