Nokea
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.
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Actual exchange of gases in the lungs occurs in the
- A. bronchi.
- B. alveoli.
- C. bronchioles.
- D. tracheas.
Correct Answer: B
Rationale: The correct answer is B: alveoli. Alveoli are tiny air sacs in the lungs where the exchange of oxygen and carbon dioxide takes place through diffusion. This process is crucial for oxygenating the blood and removing carbon dioxide. Bronchi (A), bronchioles (C), and trachea (D) are all parts of the respiratory system, but they do not participate directly in gas exchange. Bronchi are the main airways that branch off from the trachea, bronchioles are smaller airways that lead to the alveoli, and the trachea is the main airway that carries air to and from the lungs.
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is relevant because equal AP and lateral chest diameters can indicate a condition called barrel chest, often associated with chronic obstructive pulmonary disease (COPD). Clients with COPD may have increased chest diameters due to air trapping. Asking about chronic breathing problems can help the nurse further assess the client's respiratory status.
Choice A is incorrect because medications or herbal supplements are not directly related to equal AP and lateral chest diameters. Choice C is incorrect as aerobic exercise frequency does not typically impact chest diameters in this manner. Choice D is also incorrect as occupation and hobbies are not likely to be directly linked to equal chest diameters.
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?
- A. Teach the client about possible drowsiness.
- B. Instruct the client to drink plenty of water.
- C. Consult with the PHCP about the medication.
- D. Encourage the client to take the medication with food.
Correct Answer: C
Rationale: The correct answer is C: Consult with the PHCP about the medication. This is the best action because diphenhydramine may not be the most appropriate medication for older adults due to potential side effects like increased risk of falls, confusion, and urinary retention. Consulting with the PHCP will ensure that the medication is safe and effective for the client.
A: Teaching about drowsiness is important but not the priority.
B: Drinking water is generally good advice but not specific to diphenhydramine.
D: Taking medication with food can help reduce stomach upset but doesn't address the concerns related to diphenhydramine in older adults.
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.
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.