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In assessing for major sources of infection in a COPD patient, the nurse focuses on:
- A. Stasis of respiratory secretions.
- B. Low body weight.
- C. Episodes of postural hypotension.
- D. Delayed antigen-antibody response.
Correct Answer: A
Rationale: The correct answer is A: Stasis of respiratory secretions. In COPD patients, stasis of respiratory secretions can lead to bacterial growth and increase the risk of infections like pneumonia. This is a common issue in COPD due to impaired mucociliary clearance. Choices B, C, and D are not directly related to sources of infection in COPD patients. Low body weight is more associated with malnutrition, postural hypotension with cardiovascular issues, and delayed antigen-antibody response with immune system deficiencies.
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The impulse for voluntary muscles for forced breathing starts in
- A. Medulla ( pons )
- B. Vagus nerve
- C. Cerebral hemispheres
- D. Spinal cord
Correct Answer: A
Rationale: The correct answer is A: Medulla (pons). The medulla, located in the brainstem, controls involuntary functions like breathing. Specifically, the medulla contains the respiratory center, which regulates breathing rhythm and depth. During forced breathing, the medulla sends impulses to the voluntary muscles involved in breathing, such as the diaphragm and intercostal muscles. The pons, which is closely connected to the medulla, assists in regulating breathing patterns. The vagus nerve (B) is responsible for parasympathetic functions, not voluntary breathing. The cerebral hemispheres (C) are primarily involved in higher brain functions, not breathing regulation. The spinal cord (D) plays a role in transmitting signals between the brain and muscles but does not initiate voluntary breathing impulses.
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?
- A. Assess the client's pain level.
- B. Keep the client's head elevated.
- C. Teach the client about the causes of nasal bleeding.
- D. Assess the client's airway.
Correct Answer: D
Rationale: The correct answer is D: Assess the client's airway. This is the priority action as airway patency is always the top priority in any emergency situation. In this case, posterior nasal bleeding can lead to blood flow into the throat, potentially obstructing the airway. Ensuring the client's airway is clear and maintaining adequate oxygenation is crucial for their safety.
Choice A (Assess the client's pain level) is not the priority when there is a potential risk to the airway. Choice B (Keep the client's head elevated) may be done after confirming airway patency. Choice C (Teach the client about the causes of nasal bleeding) is important but not the immediate priority in this situation.
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, 'What exactly is this test for?' What would be the nurse's best response?
- A. A PFT measures how much air moves in and out of your lungs when you breathe.
- B. A PFT measures how much energy you get from the oxygen you breathe.
- C. A PFT measures how elastic your lungs are.
- D. A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.
Correct Answer: A
Rationale: The correct answer is A because a pulmonary function test (PFT) measures lung function by assessing how much air moves in and out of the lungs when breathing. This test helps diagnose conditions like emphysema by evaluating lung capacity and air flow. Choice B is incorrect because PFTs do not measure energy obtained from oxygen, but rather focus on lung function. Choice C is incorrect as PFTs do not specifically measure lung elasticity. Choice D is incorrect because PFTs primarily assess air movement in the lungs, not the exchange of oxygen and carbon dioxide between the lungs and blood.
During inspiration, air passes into lungs due to
- A. Increase in volume of thoracic cavity and fall in lung pressure
- B. Fall in pressure inside the lungs
- C. Increased volume of thoracic cavity
- D. Muscular expansion of lungs
Correct Answer: A
Rationale: Correct Answer: A - Increase in volume of thoracic cavity and fall in lung pressure
Rationale:
1. During inspiration, the diaphragm contracts and moves downward, increasing the volume of the thoracic cavity.
2. The external intercostal muscles also contract, lifting the ribcage and further expanding the thoracic cavity.
3. As thoracic cavity volume increases, lung pressure decreases, creating a pressure gradient that allows air to flow into the lungs.
Summary:
B: Fall in pressure inside the lungs - This is a consequence of the increase in thoracic cavity volume, not the cause of air entering the lungs.
C: Increased volume of thoracic cavity - This is correct but does not explain how air enters the lungs.
D: Muscular expansion of lungs - Lungs do not expand on their own; it is the thoracic cavity that expands to create the pressure gradient for air entry.
In planning care for the patient with bronchiectasis, which nursing intervention should the nurse include?
- A. Relieve or reduce pain
- B. Prevent paroxysmal coughing
- C. Prevent spread of the disease to others
- D. Promote drainage and removal of mucus
Correct Answer: D
Rationale: In planning care for the patient with bronchiectasis, the nurse should include promoting drainage and removal of mucus to prevent further complications and improve respiratory function.