Nokea
A client who is found unresponsive has the following arterial blood gases: pH 7.12,
PCO2 90, and HCO3 26. The nurse interprets the results as indicating which
condition?
- A. Metabolic acidosis with partial compensation
- B. Respiratory acidosis with partial compensation
- C. Metabolic acidosis without compensation
- D. Respiratory acidosis without compensation
Correct Answer: D
Rationale: The correct answer is D, respiratory acidosis without compensation. The low pH and high PCO2 levels indicate respiratory acidosis. HCO3 is within normal range, suggesting no metabolic compensation. This is not metabolic acidosis as the HCO3 level is not elevated. Not partial compensation as the HCO3 level is not compensating for the respiratory acidosis.
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A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically turn the oxygen down or off.
- C. Replaces the oxygen tubing with a different type.
- D. Turn the client every 2 hours or as needed.
Correct Answer: A
Rationale: The correct answer is A because applying water-soluble ointment to nares and lips helps prevent skin breakdown and discomfort caused by the oxygen flow. This task is within the scope of practice for assistive personnel (AP) as it does not require specialized medical knowledge or training.
Choice B is incorrect because adjusting oxygen flow should only be done by licensed healthcare providers based on the client's prescribed oxygen therapy. Choice C is incorrect as replacing oxygen tubing requires knowledge of oxygen delivery systems and potential risks associated with incorrect tubing selection. Choice D is incorrect because turning the client every 2 hours is a nursing intervention related to preventing pressure ulcers, not specifically related to oxygen therapy comfort measures.
Mammalian lungs have numerous alveoli for
- A. Increasing the volume of inspired air
- B. Keeping the lungs in proper shape
- C. Higher number of muscles to provide greater elasticity
- D. Increasing surface area for gaseous diffusion
Correct Answer: D
Rationale: The correct answer is D because alveoli increase the surface area for gaseous diffusion, facilitating efficient exchange of oxygen and carbon dioxide in the lungs. Alveoli are tiny air sacs where gas exchange occurs. Option A is incorrect as alveoli do not affect the volume of inspired air. Option B is incorrect as alveoli do not play a role in maintaining lung shape. Option C is incorrect as alveoli do not increase muscles in the lungs for elasticity. Therefore, the primary function of alveoli is to increase surface area for gaseous diffusion, making option D the correct choice.
The COPD patient delightedly tells the nurse that he has quit smoking and is using chewing tobacco. The nurse's best intervention would be to:
- A. Congratulate him on his quitting smoking.
- B. Warn him of the dangers of oral cancer.
- C. Suggest that he add nicotine patches in addition to the chewing tobacco.
- D. Point out that he is still addicted and is using tobacco.
Correct Answer: D
Rationale: The correct answer is D. The nurse should point out that the patient is still addicted and using tobacco. This is important because quitting smoking is a positive step, but using chewing tobacco still poses health risks. By highlighting the addiction and continued use of tobacco, the nurse can provide necessary education and support for the patient's overall health.
Choice A is incorrect because it fails to address the continued tobacco use. Choice B is also incorrect as it focuses on a specific risk (oral cancer) rather than the broader issue of tobacco addiction. Choice C is incorrect as adding nicotine patches would not address the fact that the patient is still using tobacco in another form.
How many lobes does each lung have, and which lung has a cardiac notch?
- A. right lung has 2 lobes, the left lung has 3 lobes; the right lung has a cardiac notch
- B. right lung has 3 lobes, the left lung has 2 lobes; the right lung has a cardiac notch
- C. right lung has 2 lobes, the left lung has 3 lobes; the left lung has a cardiac notch
- D. right lung has 3 lobes, the left lung has 2 lobes; the left lung has a cardiac notch
Correct Answer: D
Rationale: Step 1: Identifying lobes - The right lung has 3 lobes (upper, middle, lower) while the left lung has 2 lobes (upper, lower).
Step 2: Cardiac notch - The cardiac notch is a concave space on the left lung where the heart lies. Therefore, the left lung has a cardiac notch.
Step 3: Correct choice - Option D states that the right lung has 3 lobes, the left lung has 2 lobes, and the left lung has a cardiac notch, which aligns with the anatomical features of the lungs.
Step 4: Incorrect choices - Choices A, B, and C have incorrect combinations of lobes and the presence of a cardiac notch, making them incorrect.
The concentration of nitrogen in the earth's atmosphere is approximately
- A. 78 percent.
- B. 66 percent.
- C. 50 percent
- D. 33 percent
Correct Answer: A
Rationale: The correct answer is A: 78 percent. The rationale is based on the fact that nitrogen makes up approximately 78% of the Earth's atmosphere. This is a well-known scientific fact supported by various studies and measurements. Option B, C, and D are incorrect as they do not align with the established data on the composition of the Earth's atmosphere. Nitrogen is the most abundant gas in the atmosphere, followed by oxygen, which is around 21%. Therefore, option A is the correct choice based on scientific evidence and consensus.