Nokea
A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. Being aware of the patient’s condition, what approach should the nurse use to assess the patient’s lungs?
- A. Apex to base
- B. Base to apex
- C. Lateral sequence
- D. Anterior then posterior
Correct Answer: D
Rationale: In a patient with severe shortness of breath, the nurse should assess the lungs using a posterior to anterior approach to minimize discomfort and optimize assessment in compromised patients.
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A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need NOT to assess before teaching this particular client?
- A. Cognition
- B. Dexterity
- C. Hydration
- D. Range of motion
Correct Answer: C
Rationale: The correct answer is C. Hydration is not directly related to tracheostomy care. The rationale is: A) Cognition is important for understanding and following care instructions. B) Dexterity is needed for handling tracheostomy equipment. C) Hydration, while important for overall health, does not directly impact tracheostomy care. D) Range of motion is relevant to prevent complications like skin breakdown. In summary, hydration is not a crucial factor to assess specifically for tracheostomy care compared to cognition, dexterity, and range of motion.
The filtering and keeping the mucus and dirt away from our lung's performed by
- A. cilia
- B. bronchioles
- C. hair in lungs
- D. all of the above
Correct Answer: A
Rationale: The correct answer is A: cilia. Cilia are tiny hair-like structures in the respiratory tract that sweep mucus and dirt out of the lungs to keep them clean. Bronchioles are small airways in the lungs through which air passes, not involved in filtering. Hair in the lungs is not a natural structure; it would be harmful. Choice D is incorrect because not all options listed are involved in filtering and keeping the mucus and dirt away from the lungs.
Which type of acid-base imbalance can result from the inhibition of carbonic anhydrase?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: Carbonic anhydrase catalyzes the conversion of carbon dioxide and water into carbonic acid, which then dissociates into bicarbonate and hydrogen ions. Inhibition of carbonic anhydrase leads to decreased bicarbonate levels, causing metabolic alkalosis. Without adequate bicarbonate, the body accumulates excess base, resulting in alkalosis. Metabolic acidosis (A) is incorrect because inhibition of carbonic anhydrase would lead to excess base, not acid. Respiratory acidosis (B) and respiratory alkalosis (D) are incorrect as they are caused by respiratory, not metabolic, disturbances.
The function of tracheal cilia is to
- A. Pass mucus out
- B. Pass mucus in
- C. Pass air out
- D. Pass air out
Correct Answer: A
Rationale: The correct answer is A: Pass mucus out. Tracheal cilia help move mucus, which contains dust, debris, and pathogens, out of the respiratory tract to prevent infections and maintain clear airways. This process is known as mucociliary clearance. Choices B, C, and D are incorrect because tracheal cilia do not pass mucus in, pass air out, or pass air in. Tracheal cilia specifically function to clear mucus out of the respiratory tract.
A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?
- A. Are any family members also ill?
- B. Have you traveled recently?
- C. How long have you been ill?
- D. What is your occupation?
Correct Answer: D
Rationale: The correct answer is D: What is your occupation? This is the most important question because inhalation anthrax is commonly associated with certain occupations, like handling animal products or working in agricultural settings. Knowing the client's occupation can help identify potential sources of exposure.
A: Are any family members also ill? - While important for assessing potential spread of infection, this question does not directly help in determining the cause of the anthrax infection.
B: Have you traveled recently? - Travel history is relevant for certain infectious diseases, but for inhalation anthrax, occupational exposure is a more crucial factor to consider.
C: How long have you been ill? - Timing of symptoms is important for diagnosis and treatment, but knowing the client's occupation provides more specific information in the case of suspected inhalation anthrax.