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A 68-year-old male is being admitted to the hospital for an exacerbation of his COPD. The nurse is developing his plan of care. The nurse can expect that this client will?
- A. Be placed on 10 L of oxygen per nasal cannula.
- B. Be placed in respiratory isolation.
- C. Require frequent rest periods throughout the day.
- D. Be placed on fluid restriction.
Correct Answer: C
Rationale: The correct answer is C: Require frequent rest periods throughout the day. This is because patients with COPD often experience shortness of breath and fatigue, necessitating frequent rest periods to conserve energy and manage symptoms. Oxygen therapy is typically started at a lower flow rate (2-4 L/min) to avoid suppressing the patient's respiratory drive, so option A is not appropriate. Respiratory isolation is unnecessary for COPD exacerbation, as it is not a contagious condition, making option B incorrect. Fluid restriction is not typically indicated for COPD exacerbation unless the patient has comorbid conditions like heart failure, so option D is not the priority.
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A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?
- A. Measure oxygen saturation before and after a 12-minute walk.
- B. Verify that the client understands all possible complications.
- C. Explain the procedure in detail to the client and the family.
- D. Validate that informed consent has been given by the client.
Correct Answer: D
Rationale: The correct answer is D. Validating that informed consent has been given by the client is crucial before any invasive procedure to ensure the client understands the risks, benefits, and alternatives. It also respects the client's autonomy and right to make an informed decision.
A: Measuring oxygen saturation before and after a 12-minute walk is not directly related to thoracentesis preparation.
B: Verifying the client's understanding of complications is important but not the immediate priority before the procedure.
C: Explaining the procedure to the client and family is essential but may not be the first step; ensuring informed consent comes before this step.
Hiccup is due to
- A. Increased inspiration
- B. Irritation of Phrenic nerve
- C. Expanded stomach
- D. Acidity in the stomach
Correct Answer: B
Rationale: The correct answer is B because hiccups are caused by the irritation of the phrenic nerve, which controls the diaphragm muscle responsible for breathing. When the nerve is irritated, it causes the diaphragm to contract involuntarily, leading to the characteristic sound of hiccups.
Choice A (Increased inspiration) is incorrect as hiccups are not caused by increased inspiration but rather by involuntary contractions of the diaphragm.
Choice C (Expanded stomach) is incorrect as hiccups are not directly related to the size of the stomach but rather to nerve irritation.
Choice D (Acidity in the stomach) is incorrect as hiccups are not primarily caused by stomach acidity, but by nerve irritation leading to diaphragm contractions.
While assessing an older adult patient, what finding indicates left-sided heart failure?
- A. Weight gain
- B. Ascites
- C. Crackles
- D. Jugular vein distention
Correct Answer: C
Rationale: The correct answer is C: Crackles. Crackles indicate left-sided heart failure due to fluid accumulation in the lungs. This occurs when the left side of the heart is unable to efficiently pump blood, leading to fluid backing up into the lungs. Weight gain (A) may be a general sign of heart failure but is not specific to left-sided failure. Ascites (B) is more indicative of right-sided heart failure, where fluid accumulates in the abdomen. Jugular vein distention (D) is a sign of right-sided heart failure, where blood backs up into the systemic circulation causing jugular vein distention.
Which of these statements is false regarding Pulmonary Resistance?
- A. Increase in pulmonary arterial pressure generally cause a fall in pulmonary resistance
- B. Pulmonary resistance is only 1/10 of systemic circulation resistance
- C. Increase of lung volume results in increase of resistance in extra alveolar vessels
- D. Acetylcholine has a good bronchiole smooth muscle relaxation effect
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
- Increase of lung volume results in decrease, not increase, in resistance in extra alveolar vessels due to increased recruitment of capillaries.
- This is known as distension recruitment, which helps reduce resistance in extra alveolar vessels.
- Increased lung volume also helps to distribute blood flow more evenly in the lungs, reducing resistance.
- Therefore, statement C is false.
Summary of Incorrect Choices:
A: True - increase in pulmonary arterial pressure generally causes a fall in pulmonary resistance due to vessel dilation.
B: True - pulmonary resistance is indeed lower than systemic circulation resistance due to shorter pulmonary vascular bed.
D: True - acetylcholine causes bronchiole smooth muscle contraction, not relaxation.
A client is found to be allergic to Chinese food, which causes acute asthma. Which of the following instructions should the nurse give the client?
- A. "Only eat Chinese food once a month."
- B. "Use your inhalers before eating Chinese food."
- C. "Avoid Chinese food because this is a trigger for you."
- D. "Determine other causes, because Chinese food wouldn't cause such a violent reaction."
Correct Answer: C
Rationale: Rationale: Choice C is correct because avoiding Chinese food, a known trigger for the client's acute asthma, is crucial to prevent future asthma attacks. By eliminating the trigger, the client can reduce the risk of allergic reactions and asthma exacerbations.
Summary:
A: Incorrect. Eating Chinese food once a month still exposes the client to the trigger, increasing the risk of asthma attacks.
B: Incorrect. Using inhalers before eating Chinese food may help manage symptoms temporarily but does not address the root cause of the allergic reaction.
D: Incorrect. Dismissing the client's known trigger without further investigation can lead to serious health consequences.