Nokea
A 19-year-old client comes to the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears in acute respiratory distress. Which of the following actions should be taken first?
- A. Take a full medical history.
- B. Give a bronchodilator by nebulizer.
- C. Apply a cardiac monitor to the client.
- D. Provide emotional support to the client.
Correct Answer: B
Rationale: The correct answer is B: Give a bronchodilator by nebulizer. In acute asthma, the priority is to relieve respiratory distress by opening up the airways. Bronchodilators help to quickly alleviate bronchospasm and improve airflow. This action should be taken first to improve the client's breathing. Taking a full medical history (A) can be important but is not the priority in this acute situation. Applying a cardiac monitor (C) is not the immediate concern in acute asthma. Providing emotional support (D) is also important but should come after ensuring the client's respiratory distress is managed.
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When teaching a patient with heart failure on a 2000-mg sodium diet. Which foods should the nurse recommend limiting?
- A. Chicken
- B. Fresh spinach
- C. Eggs
- D. Milk
Correct Answer: D
Rationale: The correct answer is D: Milk. Milk is a high sodium food and can contribute significantly to a patient's daily sodium intake. For a patient on a 2000-mg sodium diet, it is crucial to limit high sodium foods like milk to prevent fluid retention and worsening of heart failure symptoms. Other choices (A, B, C) are lower in sodium compared to milk. Chicken, fresh spinach, and eggs are generally good protein sources with lower sodium content and can be included in moderation in a 2000-mg sodium diet for a heart failure patient.
Rate and depth of respiration shall increase when
- A. Oxygen concentration increases
- B. CO2 concentration increases
- C. Bicarbonate concentration increases
- D. Bicarbonate concentration decrease
Correct Answer: B
Rationale: The correct answer is B: CO2 concentration increases. When CO2 levels rise in the blood, it leads to an increase in the acidity of the blood, triggering the respiratory centers in the brain to increase the rate and depth of respiration in order to expel excess CO2 and restore the pH balance.
Explanation for other choices:
A: Oxygen concentration increases - An increase in oxygen concentration does not directly stimulate an increase in respiration rate or depth. The respiratory drive is primarily regulated by CO2 levels.
C: Bicarbonate concentration increases - While bicarbonate is involved in the acid-base balance in the body, it does not directly influence the rate and depth of respiration.
D: Bicarbonate concentration decreases - A decrease in bicarbonate concentration may affect acid-base balance, but it does not have a direct effect on respiratory rate and depth.
In mammals ventilation movements of lungs are governed by
- A. Muscular wall of lungs
- B. Inter costal muscles
- C. Diaphragm
- D. Diaphragm and inter coastal muscles
Correct Answer: D
Rationale: The correct answer is D: Diaphragm and intercostal muscles. The diaphragm is the primary muscle responsible for inhalation and exhalation by contracting and relaxing, respectively. Intercostal muscles aid in expanding and contracting the rib cage to assist in breathing. The combination of the diaphragm and intercostal muscles working together ensures efficient ventilation of the lungs in mammals. Choices A and B are incorrect because the muscular wall of the lungs and intercostal muscles alone are not solely responsible for regulating ventilation. Choice C is incorrect because the diaphragm alone does not govern ventilation movements without the assistance of the intercostal muscles. Therefore, the correct answer is D as it accurately reflects the coordinated effort of both the diaphragm and intercostal muscles in regulating lung ventilation.
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis?
- A. Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall
- B. Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall
- C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
- D. Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall
Correct Answer: C
Rationale: The correct answer is C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub are consistent with pleural effusion. Dullness on percussion indicates fluid accumulation in the pleural space. Absent breath sounds suggest decreased air movement due to the fluid. A pleural friction rub may be heard due to inflammation of the pleura.
A is incorrect because increased tactile fremitus, egophony, and a dull sound upon percussion are more indicative of pneumonia.
B is incorrect because decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion are more indicative of COPD or emphysema.
D is incorrect because normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion are more indicative of asthma or atelectasis.
A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client's chest wall, the nurse expects to elicit:
- A. Resonant sounds.
- B. Hyperresonant sounds.
- C. Dull sounds.
- D. Flat sounds.
Correct Answer: A
Rationale: The correct answer is A: Resonant sounds. Percussing the chest of a healthy individual typically elicits resonant sounds due to the presence of air-filled lung tissue. In this case, the client has a history of asthma, which indicates airway inflammation and possible mucus accumulation, making resonant sounds more likely. Hyperresonant sounds (B) are typically heard in conditions like emphysema with increased lung volume. Dull sounds (C) are indicative of fluid or solid tissue present in the lungs, which is not expected in this client. Flat sounds (D) are heard over areas of solid tissue or muscle, not in the chest of a client with respiratory conditions.