Nokea
A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?
- A. Leg movement
- B. Finger movement
- C. Lip movement
- D. Fighting the ventilator
Correct Answer: D
Rationale: The correct answer is D: Fighting the ventilator. This indicates inadequate muscle relaxation, requiring another dose of pancuronium. Leg, finger, and lip movements are not reliable indicators of muscle relaxation in a mechanically ventilated patient. Fighting the ventilator suggests the patient is not adequately sedated or paralyzed, requiring further intervention to maintain optimal ventilation and oxygenation.
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A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?
- A. Limiting fluid.
- B. Having the client take deep breaths.
- C. Asking the client to spit into the collection container.
- D. Asking the client to obtain the specimen after eating.
Correct Answer: B
Rationale: The correct answer is B: Having the client take deep breaths. This action facilitates obtaining a sputum specimen by helping the client to cough and expectorate sputum effectively. Deep breaths help to mobilize secretions, making it easier for the client to produce a quality specimen. Limiting fluid intake (choice A) can lead to dehydration and thickening of secretions, making it harder to obtain a specimen. Asking the client to spit into the container (choice C) may result in contamination with saliva. Asking the client to obtain the specimen after eating (choice D) can introduce food particles into the specimen, affecting the accuracy of the test.
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.
The term hypercapnia refers to
- A. the cessation of breathing
- B. elevated PCO2
- C. elevated PO2
- D. an increase in pH
Correct Answer: B
Rationale: Step 1: Understand the term - Hypercapnia means increased levels of CO2 in the blood.
Step 2: Elevated PCO2 directly relates to increased CO2 levels.
Step 3: This condition can lead to respiratory issues due to excess CO2.
Step 4: Therefore, choice B, elevated PCO2, is the correct answer.
Summary: Choices A, C, and D are incorrect as hypercapnia specifically refers to increased CO2 levels, not the cessation of breathing, elevated PO2, or an increase in pH.
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.
Which of the following structures most is responsible for determining pulmonary resistance?
- A. visceral and parietal pleura
- B. Trachea
- C. Bronchi
- D. Bronchioles
Correct Answer: D
Rationale: The correct answer is D: Bronchioles. Bronchioles are the smallest airways in the lungs and play a crucial role in determining pulmonary resistance. They have smooth muscle surrounding them, which can contract or relax to regulate airflow and resistance. Constriction of bronchioles increases resistance, while dilation decreases it. Visceral and parietal pleura (A) are membranes that cover the lungs and chest wall, not directly involved in determining pulmonary resistance. The trachea (B) and bronchi (C) are larger airways that mainly serve as conduits for air passage and do not have as significant an impact on resistance as the bronchioles do.