Nokea
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 assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first?
- A. Facial pain
- B. Vital signs
- C. Bone displacement
- D. Airway patency
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Ensuring airway patency is the top priority in any client assessment, especially in cases of facial trauma like a nasal fracture. This is because compromised airway can lead to respiratory distress or failure. Assessing airway patency should always be the first step to ensure the client's ability to breathe.
Facial pain (A) may be important but does not address immediate life-threatening concerns. Vital signs (B) are important but assessing airway patency takes precedence for client safety. Bone displacement (C) is relevant but does not address the immediate need to maintain airway patency.
When does oxyhemoglobin form during respiration?
- A. during external respiration
- B. immediately after carbon dioxide enters the blood
- C. when the chloride shift occurs
- D. during pulmonary ventilation
Correct Answer: A
Rationale: The correct answer is A, during external respiration. Oxyhemoglobin forms when oxygen binds to hemoglobin in the lungs during external respiration. This process occurs in the alveoli where oxygen diffuses from the air sacs into the blood, binding with hemoglobin to form oxyhemoglobin. Choices B, C, and D are incorrect because oxyhemoglobin formation specifically happens during external respiration, not immediately after carbon dioxide enters the blood, when the chloride shift occurs, or during pulmonary ventilation. These processes are important in respiration but do not directly involve the formation of oxyhemoglobin.
If the CO2 concentration in the blood increases, the breathing shall
- A. Increase
- B. Decrease
- C. Stop
- D. No affect
Correct Answer: A
Rationale: When CO2 concentration in the blood increases, it leads to respiratory acidosis, causing the body to increase breathing rate to expel excess CO2 and restore pH balance. This increase in breathing helps eliminate CO2 through exhalation, thus the correct answer is A.
Choice B is incorrect because an increase in CO2 concentration triggers an increase in breathing to remove the excess CO2, not decrease it.
Choice C is incorrect because stopping breathing would be life-threatening and is not a physiological response to high CO2 levels.
Choice D is incorrect because an increase in CO2 concentration does have an effect on breathing rate to maintain homeostasis.
The fauces connects which of the following structures to the oropharynx?
- A. nasopharynx
- B. laryngopharynx
- C. nasal cavity
- D. oral cavity
Correct Answer: D
Rationale: The correct answer is D: oral cavity. The fauces is the opening between the oral cavity and the oropharynx. It is located at the back of the mouth, connecting the oral cavity to the oropharynx. This opening allows the passage of food and liquids from the mouth to the throat during swallowing. Choices A, B, and C are incorrect because the fauces does not connect to the nasopharynx, laryngopharynx, or nasal cavity. The fauces specifically connects the oral cavity to the oropharynx, making choice D the correct answer in this context.
Which of the following symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
- A. Pain when talking
- B. Burning in the throat
- C. Increased nasal swelling
- D. Presence of laryngospasm
Correct Answer: D
Rationale: The correct answer is D. Laryngospasm is a serious symptom that requires immediate attention in upper airway trauma. A (pain when talking) and B (burning in the throat) are less urgent. C (increased nasal swelling) is a local finding but not life-threatening.