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A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported?
- A. Hot, flushed feeling.
- B. Sudden chills and fever.
- C. Chest pain that occurs suddenly.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: The correct answer is C: Chest pain that occurs suddenly. Pulmonary embolism typically presents with sudden chest pain due to a blockage in the pulmonary arteries. This is a result of a blood clot traveling to the lungs, causing a sharp and stabbing pain. The other options are not typically associated with pulmonary embolism. A hot, flushed feeling (A) is more indicative of a fever or infection, sudden chills and fever (B) may occur in sepsis or the flu, and nausea and vomiting (D) are more commonly seen in gastrointestinal issues.
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All of the following pairings are correct (assuming normal person at rest) EXCEPT
- A. Tidal volume = 500 ml
- B. Alveolar ventilation = 7500 ml
- C. Pulmonary blood flow = 5000 ml/min
- D. Functional residual capacity = volume of gas in lung after normal expiration
Correct Answer: B
Rationale: The correct answer is B: Alveolar ventilation = 7500 ml. Alveolar ventilation is the volume of fresh air that reaches the alveoli per minute. It is calculated by subtracting the dead space ventilation from the tidal volume and then multiplying by the respiratory rate. In a normal person at rest, the average alveolar ventilation is around 4200 ml/min, not 7500 ml/min. Therefore, choice B is incorrect. Choices A, C, and D are correct because tidal volume is typically around 500 ml, pulmonary blood flow is about 5000 ml/min, and functional residual capacity is the volume of gas in the lung after normal expiration.
A client with bronchitis is admitted to the hospital. What would the nurse expect the admitting assessment NOT to reveal?
- A. Cough
- B. Bloody sputum
- C. Chest pain
- D. Bradycardia
Correct Answer: D
Rationale: The correct answer is D: Bradycardia. In bronchitis, the body typically responds to inflammation by increasing heart rate (tachycardia) to improve oxygen delivery. Bradycardia is not a common finding in bronchitis and would be unexpected. Choices A, B, and C are commonly associated with bronchitis due to the inflammation in the airways causing cough, production of bloody sputum, and chest pain. These symptoms are typical manifestations of bronchitis and would be expected in the admitting assessment.
Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis, nasal drainage normally is:
- A. Yellow
- B. Green
- C. Clear
- D. Gray
Correct Answer: C
Rationale: The correct answer is C: Clear. In acute rhinitis, the nasal drainage is typically clear because it is caused by viral infections or allergies, which result in clear mucus production. Yellow or green drainage may indicate a bacterial infection, which is not typically associated with acute rhinitis. Gray drainage is uncommon in nasal discharge and may suggest a more serious underlying condition. Therefore, the nurse asked about the color of the drainage to assess the nature of the infection and determine the appropriate course of treatment.
Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:
- A. Dyspnea
- B. Chest pain
- C. A bloody, productive cough.
- D. Bronchoscopy
Correct Answer: B
Rationale: The correct answer is B: Chest pain. Chest pain can be one of the first symptoms of tuberculosis due to inflammation of the lung tissue or pleura. Dyspnea (A) typically occurs in later stages as the disease progresses. A bloody, productive cough (C) is a common symptom of tuberculosis but may not be one of the first symptoms. Bronchoscopy (D) is a diagnostic procedure and not a symptom of tuberculosis. In summary, chest pain is a common initial symptom due to lung inflammation, while the other choices are either later symptoms or unrelated diagnostic procedures.
The home health nurse is educating a 60-year-old patient with emphysema with a nutritional deficit. Which instructions should the nurse avoid including in the teaching plan to address this problem?
- A. Rest before eating.
- B. Avoiding gas-producing foods.
- C. Eat four to six small meals instead of three large meals.
- D. Lie down after eating.
Correct Answer: D
Rationale: The correct answer is D because lying down after eating can increase the risk of acid reflux and heartburn in patients with emphysema.
A: Rest before eating is important as it can reduce shortness of breath during meals.
B: Avoiding gas-producing foods can help prevent bloating and discomfort.
C: Eating four to six small meals instead of three large meals is beneficial for easier digestion and energy management.
In summary, D is incorrect because it can worsen symptoms, while A, B, and C are all helpful strategies for managing nutritional deficits in patients with emphysema.