Nokea
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:
- A. Lips
- B. Mucous membranes
- C. Nail beds
- D. Earlobes
Correct Answer: B
Rationale: The correct answer is B: Mucous membranes. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an important sign of respiratory distress. In individuals with dark skin, cyanosis may be more easily detected in the mucous membranes, such as the lips and oral mucosa, compared to the skin. The lips (choice A), nail beds (choice C), and earlobes (choice D) may not always show cyanosis clearly in individuals with darker skin tones. Therefore, assessing the mucous membranes is the best option for identifying cyanosis accurately in this scenario.
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Which of the following processes does atmospheric pressure play a role in?
- A. pulmonary ventilation
- B. production of pulmonary surfactant
- C. resistance
- D. surface tension
Correct Answer: A
Rationale: The correct answer is A: pulmonary ventilation. Atmospheric pressure plays a crucial role in pulmonary ventilation by creating a pressure gradient that allows air to flow into and out of the lungs during inhalation and exhalation. When the atmospheric pressure is higher than the pressure inside the lungs, air moves in (inhalation); when the pressure inside the lungs is higher, air moves out (exhalation).
Summary of why the other choices are incorrect:
B: Production of pulmonary surfactant is not directly influenced by atmospheric pressure. Pulmonary surfactant reduces surface tension in the alveoli to prevent collapse.
C: Resistance in the respiratory system is mainly influenced by airway diameter and elasticity of the lungs, not atmospheric pressure.
D: Surface tension in the alveoli is affected by pulmonary surfactant, not atmospheric pressure.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on which finding?
- A. SpO of 86%
- B. Crackles in both lower lobes
- C. Temperature of 101.4ºF (38.6ºC)
- D. Production of greenish purulent sputum
Correct Answer: A
Rationale: Impaired gas exchange is indicated by a low SpO2 level, in this case 86%, which suggests inadequate oxygenation. Crackles, temperature, and sputum production are important assessments but do not directly indicate impaired gas exchange.
Expiration involves
- A. Relaxation of diaphragm and intercostals muscles
- B. Contraction of diaphragm and intercostals muscles
- C. Contraction of diaphragm muscles
- D. Contraction of inter costal muscles
Correct Answer: A
Rationale: The correct answer is A because expiration involves the relaxation of the diaphragm and intercostal muscles. During expiration, the diaphragm moves up and the intercostal muscles relax, causing the thoracic cavity to decrease in volume. This increase in pressure forces air out of the lungs. Choice B is incorrect as it describes the process of inspiration, not expiration. Choice C is incorrect because expiration involves both the diaphragm and intercostal muscles, not just the diaphragm muscles. Choice D is incorrect as the intercostal muscles also relax during expiration, rather than contracting.
How does the pressure 'P4' at label '4' compare to the pressure 'P5' at label '5'?
- A. P4 is higher than P5 during inhalation and then lower during exhalation
- B. P4 is always higher than P5
- C. P4 is always lower than P5
- D. P4 always equals P5
Correct Answer: C
Rationale: The correct answer is C because pressure decreases as air moves from a region of higher pressure to lower pressure. At label '4', the air pressure is higher due to inhalation, and at label '5', the pressure is lower as air exits during exhalation. Therefore, P4 is always lower than P5. Choices A and B are incorrect because pressure dynamics change during inhalation and exhalation. Choice D is incorrect as pressure imbalances exist during breathing.
Which of the following would be the most appropriate nursing intervention when caring for a client with a fractured rib?
- A. Apply immobilization device after examination by physician
- B. Discourage taking deep breaths if breathing is painful
- C. Advice against using analgesics and regional nerve blocks
- D. Encourage increased fluid intake if pulmonary contusion exists
Correct Answer: A
Rationale: The correct answer is A. Applying an immobilization device after physician evaluation helps stabilize the rib and reduce pain. B (discouraging deep breaths) is harmful as it can lead to atelectasis. C (advising against analgesics) is incorrect because pain management is essential. D (increasing fluid intake) is secondary and depends on the presence of pulmonary complications.