Nokea
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.
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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.
The impulse for voluntary muscles for forceful breathing starts in
- A. Medulla (Pons)
- B. Vagus nerve
- C. Cerebral hemispheres
- D. Spinal cord
Correct Answer: C
Rationale: The correct answer is C: Cerebral hemispheres. The impulse for voluntary muscles for forceful breathing originates in the cerebral hemispheres where conscious control over breathing is regulated. The cerebral cortex sends signals to the respiratory muscles to increase or decrease breathing effort based on the body's needs. The other choices are incorrect because:
A: Medulla (Pons) - This region of the brainstem is responsible for automatic breathing control, not voluntary forceful breathing.
B: Vagus nerve - The vagus nerve is not directly involved in initiating voluntary breathing movements.
D: Spinal cord - While the spinal cord plays a role in coordinating some aspects of breathing, it is not the primary center for voluntary forceful breathing control.
The Alveolar epithelium is lined with
- A. Non-ciliated Squamous epithelium
- B. Ciliated Squamous epithelium
- C. Ciliated epithelium
- D. Ciliated Columnar epithelium
Correct Answer: A
Rationale: The correct answer is A: Non-ciliated Squamous epithelium. The alveolar epithelium in the lungs is composed of thin, flat cells called squamous epithelium. This type of epithelium allows for efficient gas exchange by providing a short diffusion distance. Ciliated epithelium (choice C) and ciliated columnar epithelium (choice D) are not found in the alveoli as they are more suited for moving mucus and debris in the respiratory tract. Ciliated squamous epithelium (choice B) is not a common epithelial type in the alveoli and is not as thin as non-ciliated squamous epithelium, making it less efficient for gas exchange.
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.
How is a client positioned for a thoracentesis?
- A. The client sits at the side of the bed.
- B. The client lies on the affected side.
- C. The client lies flat on the back.
- D. The client lies down with the head raised.
Correct Answer: A
Rationale: The correct answer is A. For thoracentesis, the client typically sits at the edge of the bed, leaning forward with arms supported on a table or over their knees to spread out the intercostal spaces and stabilize the chest wall. B is incorrect because lying on the affected side would compress the area being accessed. C is wrong as lying flat reduces access to the pleural space. D is incorrect because raising the head is not standard positioning for this procedure.