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.
In planning care for the patient with bronchiectasis, which nursing intervention should the nurse include?
- A. Relieve or reduce pain
- B. Prevent paroxysmal coughing
- C. Prevent spread of the disease to others
- D. Promote drainage and removal of mucus
Correct Answer: D
Rationale: In planning care for the patient with bronchiectasis, the nurse should include promoting drainage and removal of mucus to prevent further complications and improve respiratory function.
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
- A. Call the physician to reinsert the tube.
- B. Grasp the retention sutures to spread the opening.
- C. Call the respiratory therapy department to reinsert the tracheotomy.
- D. Cover the tracheostomy site with a sterile dressing to prevent infection.
Correct Answer: B
Rationale: The correct initial nursing action is to choose option B: Grasp the retention sutures to spread the opening. This is because spreading the opening using the retention sutures can help maintain the airway patency until the tube is reinserted. Calling the physician (option A) or respiratory therapy department (option C) may cause delays in addressing the immediate airway obstruction. Covering the tracheostomy site with a sterile dressing (option D) does not address the primary concern of maintaining the airway. Therefore, option B is the most appropriate and effective action to take in this situation.
Internal intercostal muscles are used in ...
- A. inspiration
- B. expiration
- C. both of them
- D. pause
Correct Answer: B
Rationale: The correct answer is B: expiration. The internal intercostal muscles are used during expiration to decrease the size of the thoracic cavity, increasing the pressure in the lungs, causing air to be pushed out. During inspiration, the external intercostal muscles are used to expand the thoracic cavity. Choice A is incorrect as it refers to inspiration. Choice C is incorrect because internal intercostal muscles are not involved in both inspiration and expiration simultaneously. Choice D is incorrect as there is no specific muscle action associated with a "pause" in breathing.
Each of the following is true regarding the spleen, except:
- A. Spleen is located posterolateral to the stomach, and contacts the diaphragm and left kidney.
- B. Splenic veins, arteries, and lymphatic vessels communicate with the spleen at the hilum.
- C. The spleen is a primary lymphoid organ, serving to filter lymph fluid.
- D. Lymphocytes and dendritic cells are concentrated in the white pulp.
Correct Answer: C
Rationale: Rationale:
C is correct because the spleen is a secondary lymphoid organ, not a primary one. The spleen filters blood, not lymph fluid.
A is correct as the spleen is located in the described position.
B is correct as the splenic vessels do communicate with the spleen at the hilum.
D is correct as lymphocytes and dendritic cells are indeed concentrated in the white pulp.
Summary:
A, B, and D are correct statements about the spleen. C is incorrect because the spleen is a secondary lymphoid organ, not a primary one.