Nokea
A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess:
- A. Lung vibrations
- B. Vocal sounds
- C. Breath sounds
- D. Chest movements.
Correct Answer: D
Rationale: The correct answer is D: Chest movements. When checking respiratory status, observing chest movements, known as respiratory excursion, helps assess the depth and symmetry of breathing. This provides valuable information about lung expansion and function. Lung vibrations (A) are assessed by tactile fremitus, vocal sounds (B) by auscultating for voice sounds, and breath sounds (C) by listening for air movement in the lungs. However, these do not directly assess respiratory excursion.
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A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.
A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met?
- A. Client reports pain is controlled satisfactorily with analgesic regime.
- B. Client does not have foul odor to the breath or beefy red mucus membranes.
- C. Client is able to swallow own secretions without drooling.
- D. Client's vital signs are within normal parameters.
Correct Answer: C
Rationale: Rationale:
The correct answer is C because the ability to swallow own secretions without drooling indicates that the client's airway is patent and functional post modUPPP, a priority goal for this procedure. This assessment finding ensures that the client can maintain a clear airway and prevent complications such as aspiration.
Incorrect choices:
A: Although pain control is important, it is not a priority assessment for this specific procedure.
B: Absence of foul odor or red mucus membranes is not directly related to the airway patency or swallowing ability.
D: While normal vital signs are reassuring, they do not directly indicate the success of the surgery in improving airway function.
The organ of the respiratory system that is kept open by rings of cartilage is the:
- A. nose
- B. pharynx
- C. larynx
- D. trachea
Correct Answer: D
Rationale: The correct answer is D: trachea. The trachea is kept open by rings of cartilage to prevent collapse during inhalation. The nose (A) is primarily involved in filtering, warming, and moistening air. The pharynx (B) is a common pathway for both air and food. The larynx (C) houses the vocal cords and aids in sound production but does not have cartilage rings to keep it open.
A class of immunoglobulins found concentrated in breast milk, and thus serve to passively and naturally enhance the specific immune system of a newborn is:
- A. IgA.
- B. IgD.
- C. IgE.
- D. IgG.
Correct Answer: A
Rationale: Step 1: IgA is the correct answer. It is found in breast milk and provides passive immunity to newborns through breastfeeding.
Step 2: IgD is mainly found on the surface of B cells and is involved in the activation of B cells.
Step 3: IgE is involved in allergic responses and parasitic infections, not typically found in high concentrations in breast milk.
Step 4: IgG is the most abundant immunoglobulin in the bloodstream but is not typically concentrated in breast milk like IgA.
Summary: IgA is the correct answer because it is specifically designed to provide passive immunity to newborns through breast milk, while the other choices do not serve this function.
diaphragm relaxes and decrease thoracic space in which phase of respiration.
- A. inspiration
- B. expiration
- C. Pause
- D. both a and b
Correct Answer: B
Rationale: During expiration, the diaphragm relaxes, causing it to move upwards, which decreases the thoracic space. This leads to the expulsion of air from the lungs. In contrast, during inspiration, the diaphragm contracts and moves downwards, increasing the thoracic space to allow air to enter the lungs. Option C, Pause, does not involve any specific respiratory phase. Option D, both a and b, is incorrect because during inspiration, the diaphragm contracts and increases thoracic space. Therefore, the correct answer is B, expiration, as this phase specifically involves the relaxation of the diaphragm and the decrease in thoracic space.