Nokea
A client who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry hacking cough. Which action should the nurse take first?
- A. Auscultate the abdomen
- B. Check the capillary refill
- C. Auscultate the breath sounds
- D. Ask about the patient's allergies
Correct Answer: C
Rationale: The correct action for the nurse to take first is to auscultate the breath sounds (Choice C) because the client is presenting with severe dyspnea and a dry hacking cough, which are indicative of respiratory distress in a patient with chronic heart failure. Auscultating the breath sounds will help the nurse assess the presence of crackles, wheezing, or decreased air entry, providing crucial information about the client's respiratory status and guiding immediate interventions. Checking the capillary refill (Choice B) is important but not the priority in this situation. Auscultating the abdomen (Choice A) is not relevant to the presenting symptoms. Asking about the patient's allergies (Choice D) is important but can be addressed after addressing the immediate respiratory distress.
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What is the role of alveolar macrophages?
- A. to secrete pulmonary surfactant
- B. to secrete antimicrobial proteins
- C. to remove pathogens and debris
- D. to facilitate gas exchange
Correct Answer: C
Rationale: The correct answer is C: to remove pathogens and debris. Alveolar macrophages are specialized immune cells located in the lungs responsible for engulfing and clearing pathogens, debris, and foreign particles. This function helps maintain lung health and prevents infections.
Rationale:
1. Alveolar macrophages are part of the immune system and act as the first line of defense in the lungs.
2. Their primary role is phagocytosis, engulfing and destroying pathogens and debris to protect the respiratory system.
3. Secreting pulmonary surfactant (choice A) is the function of type II alveolar cells, not alveolar macrophages.
4. While alveolar macrophages can secrete some antimicrobial proteins (choice B), their main function is phagocytosis.
5. Facilitating gas exchange (choice D) is the role of the alveoli and not specifically of alveolar macrophages.
In summary,
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
- A. A 26-year-old woman who is 8 months pregnant.
- B. A 42-year-old man with gastroesophageal reflux disease.
- C. A 55-year-old woman who is 50 lb (23 kg) overweight.
- D. A 73-year-old man with type 2 diabetes mellitus.
Correct Answer: C
Rationale: The correct answer is C, a 55-year-old woman who is 50 lb overweight. Obesity is a major risk factor for obstructive sleep apnea (OSA) due to excess fat in the neck area that can obstruct the airway during sleep. This increases the likelihood of experiencing breathing pauses. Pregnancy (choice A) may cause temporary OSA due to hormonal changes, but it's not the greatest risk factor among the options provided. Gastroesophageal reflux disease (choice B) and type 2 diabetes mellitus (choice D) are associated with sleep disturbances, but they are not as directly linked to OSA as obesity.
Which dietary modification helps to meet the nutritional needs of patients with COPD?
- A. Eating a high-carbohydrate, low-fat diet
- B. Avoiding foods that require a lot of chewing
- C. Preparing most foods of the diet to be eaten hot
- D. Drinking fluids with meals to promote digestion
Correct Answer: B
Rationale: Patients with COPD may have difficulty chewing due to dyspnea, so avoiding foods that require a lot of chewing helps in meeting their nutritional needs. Choosing foods that are easier to eat can prevent fatigue during meals and ensure adequate nutrition intake.
Which of the following methods of speech following laryngectomy involves a throat vibrator held against the neck that projects sound into the mouth causing words to be formed with the mouth?
- A. Tracheoesophageal puncture (TEP)
- B. Esophageal speech
- C. Artificial (electric) larynx
- D. Speech therapy
Correct Answer: C
Rationale: The correct answer is C. The artificial (electric) larynx uses a throat vibrator to produce sound, enabling speech. A (TEP) involves a surgically created opening for speech. B (esophageal speech) relies on air swallowed into the esophagus. D (speech therapy) is a broader term encompassing various techniques.
A patient on the medical unit has told the nurse that he is experiencing significant
dyspnea, despite that he has not recently performed any physical activity. What
assessment question should the nurse ask the patient while preparing to perform a
physical assessment?
- A. On a scale from 1 to 10, how bad would rate your shortness of breath?
- B. When was the last time you ate or drank anything?
- C. Are you feeling any nausea along with your shortness of breath?
- D. Do you think that some medication might help you catch your breath?
Correct Answer: A
Rationale: Rationale for Correct Answer (A):
1. Assessing the severity of dyspnea is crucial for determining the urgency of intervention.
2. By asking for a rating on a scale from 1 to 10, the nurse can quantify the level of distress the patient is experiencing.
3. This allows for a more objective assessment and helps in determining appropriate interventions.
4. Monitoring changes in the severity of dyspnea over time can also guide treatment effectiveness.
Summary of Incorrect Choices:
B. Asking about the last time the patient ate or drank is important for assessing possible contributing factors to dyspnea, but it does not directly address the immediate severity of the symptom.
C. Inquiring about nausea is relevant for a more comprehensive assessment, but it does not directly address the severity of dyspnea.
D. Asking about the potential need for medication is important, but it does not directly address the current level of dyspnea and may not be the immediate priority.