Nokea
A client seen in the emergency department reports fever,fatigue and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?
- A. Collect a sputum sample for culture by deep suctioning.
- B. Inform the client that oral antibiotics will be needed for 60 days.
- C. Place the client on Airborne Precautions immediately.
- D. Tell the client that directly observed therapy is needed.
Correct Answer: B
Rationale: The correct answer is B: Inform the client that oral antibiotics will be needed for 60 days. This is the best action because the client is showing symptoms consistent with tuberculosis, such as fever, fatigue, dry cough, and mediastinal widening on chest x-ray. Treatment for tuberculosis typically involves a combination of oral antibiotics for a prolonged period, usually 6-9 months. Collecting a sputum sample for culture by deep suctioning (A) may be necessary to confirm the diagnosis but is not the priority at this moment. Placing the client on Airborne Precautions immediately (C) is important once the diagnosis is confirmed, not the initial action. Directly observed therapy (D) is a method to ensure adherence to medication but is not the immediate next step.
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Rectal respiration is seen in
- A. Cockroach
- B. Spider
- C. Niads of Dragon fly
- D. Water flea
Correct Answer: C
Rationale: Rectal respiration in insects involves the exchange of gases through the anus. The correct answer is C, Niads of Dragonfly, as they have specialized structures called rectal gills for respiration. Cockroach (A), Spider (B), and Water flea (D) do not possess rectal gills or exhibit rectal respiration. Cockroaches have spiracles for respiration, spiders have book lungs or tracheal systems, and water fleas have gills located elsewhere on their bodies. Thus, only Niads of Dragonfly demonstrate rectal respiration, making it the correct choice.
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care?
- A. Assistance with activities of daily living
- B. Physical therapy activities every day
- C. Oxygen therapy at 2 L per nasal cannula
- D. Complete bedrest with frequent repositioning
Correct Answer: A
Rationale: The correct answer is A: Assistance with activities of daily living. This intervention helps conserve the client's energy by reducing the physical exertion required for activities like climbing stairs. It promotes independence while ensuring safety and preventing further exacerbation of dyspnea. Physical therapy activities every day (B) may be too strenuous for a client experiencing dyspnea. Oxygen therapy at 2 L per nasal cannula (C) may be necessary for severe cases but does not address the client's functional limitations. Complete bedrest with frequent repositioning (D) may lead to deconditioning and worsen the client's dyspnea.
Damage to the phrenic nerves would
- A. increase respiratory rate
- B. increase the tidal volume
- C. force reliance on costal breathing
- D. result in greater pressure differences between the lungs and the outside air
Correct Answer: C
Rationale: Damage to the phrenic nerves would result in the inability to fully expand the diaphragm, leading to reliance on costal breathing. This is because the phrenic nerves innervate the diaphragm, the main muscle of respiration. Without proper diaphragmatic function, the individual would have difficulty engaging in effective diaphragmatic breathing. Therefore, choice C is correct.
Choices A, B, and D are incorrect because damage to the phrenic nerves would not directly impact the respiratory rate, tidal volume, or pressure differences between the lungs and the outside air. These functions are more related to overall respiratory control and lung mechanics, which are not solely dependent on the phrenic nerves.
During inhalation,
- A. the pressure in the thoracic cavity is greater than the pressure within the lungs.
- B. the pressure in the thoracic cavity is less than the pressure within the lungs.
- C. the diaphragm moves upward and becomes more curved.
- D. the chest cavity volume decreases.
Correct Answer: B
Rationale: During inhalation, the diaphragm contracts and moves downward, increasing the volume of the thoracic cavity. This decrease in pressure within the thoracic cavity creates a pressure gradient, causing air to flow into the lungs where the pressure is now higher. Choice B is correct because the pressure in the thoracic cavity is indeed less than the pressure within the lungs during inhalation. Choices A, C, and D are incorrect because during inhalation, the pressure in the thoracic cavity decreases, the diaphragm moves downward and flattens, and the chest cavity volume increases to allow for air intake.
Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to?
- A. Promote expectoration.
- B. Suppress the cough.
- C. Relax smooth muscles of the bronchial airway.
- D. Prevent infection.
Correct Answer: C
Rationale: The correct answer is C: Relax smooth muscles of the bronchial airway. Aminophylline (theophylline) is a bronchodilator that works by relaxing the smooth muscles in the bronchial airways, which helps to open up the airways and improve airflow. This action helps to relieve bronchospasm, which is common in conditions like acute bronchitis. Promoting expectoration (A) and suppressing cough (B) are not the primary actions of aminophylline, although they may be secondary effects. Preventing infection (D) is unrelated to the mechanism of action of aminophylline in treating acute bronchitis.