Nokea
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
- A. Administer prescribed anxiolytic medication.
- B. Ensure that informed consent is on the chart.
- C. Reinforce any teaching done previously.
- D. Start the preoperative antibiotic infusion.
Correct Answer: B
Rationale: The correct answer is B: Ensure that informed consent is on the chart. This is the priority action because obtaining informed consent is essential before any procedure to ensure that the client understands the risks, benefits, and alternatives. Administering anxiolytic medication (A) may be necessary but is not the priority. Reinforcing teaching (C) and starting antibiotics (D) are important but not as urgent as ensuring informed consent.
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What is the proper sequence in the flow of air in humans?
- A. nasal cavities, larynx, pharynx, bronchi, trachea
- B. nasal cavities, pharynx, bronchi, larynx, trachea
- C. nasal cavities, pharynx, larynx, trachea, bronchi
- D. nasal cavities, larynx, pharynx, trachea, bronchi
Correct Answer: C
Rationale: The correct sequence is C: nasal cavities, pharynx, larynx, trachea, bronchi. Air enters through the nasal cavities, passes through the pharynx, then the larynx where the vocal cords are located, then enters the trachea, and finally branches into the bronchi leading to the lungs. This sequence follows the anatomical pathway of the respiratory system, ensuring proper filtration, warming, and humidification of the air. Choices A, B, and D have incorrect sequences that do not follow the anatomical order of the respiratory pathway, leading to an inaccurate flow of air in humans.
Which area represents the work to overcome airway resistance?
- A. ABCEA
- B. ABCFA
- C. AECFA
- D. ABCDOA
Correct Answer: C
Rationale: The correct answer is C: AECFA. This sequence represents the flow of air through the respiratory system. Airway resistance is primarily overcome by the contraction and relaxation of the smooth muscles in the airways. The correct sequence includes the airway segments that actively participate in regulating airway resistance - the trachea (A), bronchi (E), and bronchioles (C and F). The other choices do not include the correct segments that are involved in overcoming airway resistance.
The combination of Hemoglobin with Oxygen in the blood can be promoted by
- A. Decreasing O2 concentration
- B. Increasing O2 concentration
- C. Increasing CO2 concentration
- D. Decreasing CO2 concentration
Correct Answer: B
Rationale: The correct answer is B: Increasing O2 concentration. When O2 concentration increases, it promotes the binding of oxygen to hemoglobin in the blood through the process of oxygenation. This results in the formation of oxyhemoglobin, which enhances oxygen transport in the blood.
Summary:
- A: Decreasing O2 concentration would hinder the binding of oxygen to hemoglobin, reducing oxygen transport efficiency.
- C: Increasing CO2 concentration would lead to the formation of carbaminohemoglobin, not oxyhemoglobin.
- D: Decreasing CO2 concentration would not directly promote the binding of oxygen to hemoglobin.
As the nurse responsible for this client's care, you anticipate which physician's orders?
- A. Endotracheal intubation and mechanical ventilation
- B. Immediate application of CPAP to client's nose and mouth
- C. Intravenous furosemide (Lasix) 100 mg IV push stat
- D. Call a CODE for respiratory arrest.
Correct Answer: A
Rationale: The correct answer is A. Poor oxygenation despite non-rebreather mask suggests impending respiratory failure, necessitating intubation and mechanical ventilation. CPAP (B) and Lasix (C) may be considered but are secondary. Calling a CODE (D) is only if respiratory arrest occurs.
What is heart failure?
- A. A sudden stoppage of the heart
- B. Inability of the heart to pump blood effectively
- C. Accumulation of excess cholesterol in the arteries
- D. Irregular heartbeat
Correct Answer: B
Rationale: The correct answer is B: Inability of the heart to pump blood effectively. Heart failure occurs when the heart is unable to pump blood efficiently to meet the body's needs. This can lead to symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation:
1. Heart failure is a chronic condition that develops over time due to various factors such as high blood pressure, heart attacks, or heart muscle damage.
2. The inability of the heart to pump blood effectively results in reduced blood flow to the body's organs and tissues.
3. This can lead to a buildup of fluid in the lungs and other parts of the body, causing symptoms like shortness of breath and swelling.
4. A sudden stoppage of the heart (Choice A) would result in cardiac arrest, not heart failure.
5. Accumulation of excess cholesterol in the arteries (Choice C) refers to atherosclerosis, not heart failure.
6. An irregular heartbeat (Choice D) may be a symptom