Nokea
A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.
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In teaching a patient with hypertension about controlling the illness the nurse recognizes that?
- A. All patients with elevated BP need drug therapy.
- B. Obese persons must achieve a normal weight to lower BP.
- C. It is not necessary to limit salt in the diet if taking a diuretic.
- D. Lifestyle modifications are needed for all persons with elevated BP.
Correct Answer: D
Rationale: Rationale:
D is correct because lifestyle modifications, such as exercise and diet changes, are essential for managing hypertension. This approach can help lower blood pressure without the need for drug therapy. A is incorrect because not all patients with elevated BP require medication. B is incorrect as weight loss is beneficial but not the only factor in controlling BP. C is incorrect because limiting salt intake remains important even if taking a diuretic.
During swallowing, the glottis is covered by
- A. false vocal cord
- B. true vocal cord
- C. epiglottis
- D. Adam's apple
Correct Answer: C
Rationale: The epiglottis covers the glottis during swallowing to prevent food or liquid from entering the airway. This helps protect the lungs from aspiration. False vocal cords (A) are not directly involved in this process. True vocal cords (B) are responsible for producing sound and are located below the glottis. Adam's apple (D) is the laryngeal prominence formed by the thyroid cartilage and does not cover the glottis during swallowing. Therefore, the correct answer is C (epiglottis).
Most of the carbon dioxide produced by the body is transported to the lungs in
- A. a gaseous form
- B. blood plasma.
- C. potassium carbonate ions.
- D. bicarbonate ions.
Correct Answer: D
Rationale: The correct answer is D: bicarbonate ions. When carbon dioxide is produced by the body, it combines with water in the blood to form carbonic acid. This carbonic acid then dissociates into bicarbonate ions and hydrogen ions. The majority of the carbon dioxide is transported in the blood as bicarbonate ions, which are more soluble and can easily travel to the lungs where they are converted back into carbon dioxide for exhalation. Choices A, B, and C are incorrect because carbon dioxide is primarily transported in the form of bicarbonate ions, not as a gas, in blood plasma, or as potassium carbonate ions.
Which of the following Hormone is secreted in excess when a person climbing a mountain
- A. Anti Natriuretic Factor
- B. Adrelaline
- C. Erythropoietin
- D. Thyroxine
Correct Answer: C
Rationale: The correct answer is C: Erythropoietin. When climbing a mountain, the body experiences reduced oxygen levels, triggering the release of erythropoietin to stimulate red blood cell production and improve oxygen delivery. This helps counteract the effects of high altitude.
Explanation of other choices:
A: Anti Natriuretic Factor - This hormone regulates sodium and water balance in the body, not directly related to climbing a mountain.
B: Adrenaline - Released in response to stress or danger, not specifically related to climbing a mountain.
D: Thyroxine - Regulates metabolism and energy levels, not directly related to the physiological response to climbing a mountain.
The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions shouldn't the nurse include in the teaching plan?
- A. Place contaminated tissues in sealable plastic bag.
- B. Take medications exactly as directed.
- C. Implement airborne precautions.
- D. Wash hands frequently.
Correct Answer: C
Rationale: The correct answer is C because TB is transmitted through droplet transmission, not airborne. The nurse should include hand hygiene (D) to prevent spread through contact, proper medication adherence (B) to treat TB effectively, and proper disposal of contaminated materials (A) to prevent spread through fomites. Implementing airborne precautions is not necessary for TB, as it does not remain suspended in the air for long periods.