Nokea
A male patient's X-ray result reveals bilateral white-outs, indicating acute respiratory distress syndrome (ARDS). This syndrome results from:
- A. Cardiogenic pulmonary edema
- B. Respiratory alkalosis
- C. Increased pulmonary capillary permeability
- D. Renal failure
Correct Answer: C
Rationale: The correct answer is C: Increased pulmonary capillary permeability. ARDS is characterized by damage to the alveolar-capillary membrane, leading to increased permeability and leakage of fluid into the alveoli. This causes bilateral white-outs on X-ray. Cardiogenic pulmonary edema (A) results from heart failure, not ARDS. Respiratory alkalosis (B) is a condition of elevated blood pH due to hyperventilation, not a direct cause of ARDS. Renal failure (D) is not a direct cause of ARDS, although it can contribute to fluid overload. Thus, the most accurate choice is C due to the pathophysiological mechanism of ARDS.
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You are supervising a nursing student who is providing care for a thoracotomy client with a chest tube. What finding will you clearly instruct the nursing student to notify you about immediately?
- A. Chest tube drainage of 10-15 mL per hour
- B. Continuous bubbling in the water seal chamber
- C. Complaints of pain at the chest tube site
- D. Chest tube dressing dated yesterday.
Correct Answer: B
Rationale: The correct answer is B. Continuous bubbling in the water seal chamber indicates an air leak and potential complications. Drainage of 10-15 mL/hour (A) is normal. Pain complaints (C) and outdated dressing (D) are less urgent.
Identify the inconsistent value in these measurements on a mixed venous blood sample obtained in a healthy person from IVC at sea level
- A. pO2 = 40mmHg
- B. pCO2 = 48mmHg
- C. PN2 = 620mmHg
- D. O2 content = 150ml/L blood
Correct Answer: C
Rationale: The correct answer is C: PN2 = 620mmHg. This is the inconsistent value because the normal partial pressure of nitrogen in venous blood is around 40 mmHg, not 620 mmHg. This discrepancy indicates an abnormal measurement. The other choices (A, B, D) are within expected ranges for a mixed venous blood sample in a healthy person at sea level. Choice A (pO2 = 40mmHg) is typical for venous blood, choice B (pCO2 = 48mmHg) falls within the normal range, and choice D (O2 content = 150ml/L blood) is a reasonable value for mixed venous blood.
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.
Damage to the phrenic nerves would
- A. increase respiratory rate
- B. increase the tidal volume
- C. force reliance on costal breathing
- D. result in greater pressure differences between the lungs and the outside air
Correct Answer: C
Rationale: Damage to the phrenic nerves would result in the inability to fully expand the diaphragm, leading to reliance on costal breathing. This is because the phrenic nerves innervate the diaphragm, the main muscle of respiration. Without proper diaphragmatic function, the individual would have difficulty engaging in effective diaphragmatic breathing. Therefore, choice C is correct.
Choices A, B, and D are incorrect because damage to the phrenic nerves would not directly impact the respiratory rate, tidal volume, or pressure differences between the lungs and the outside air. These functions are more related to overall respiratory control and lung mechanics, which are not solely dependent on the phrenic nerves.
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.