Nokea
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. The client rates pain as a 5/10 at the site of the procedure.
- B. A small amount of drainage from the site is noted.
- C. Pulse oximetry is 93% on 2 liters of oxygen.
- D. The trachea is deviated toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because tracheal deviation indicates a potential pneumothorax, a life-threatening complication of thoracentesis. Trachea should be midline. A, B, and C are incorrect because mild pain, small drainage, and slightly decreased oxygen saturation are expected findings post-thoracentesis and do not necessitate immediate action.
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The nurse assessing the CBC of a patient with chronic bronchitis identifies a typical feature of this disease, which is:
- A. Decreased platelets.
- B. Decreased white blood cells.
- C. Increased eosinophils.
- D. Increased red blood cells.
Correct Answer: D
Rationale: The correct answer is D: Increased red blood cells. In chronic bronchitis, the body compensates for chronic hypoxia by increasing red blood cell production (erythropoiesis) to improve oxygen delivery. This is known as polycythemia. Decreased platelets (A) and white blood cells (B) are not typical features of chronic bronchitis. Increased eosinophils (C) are more commonly associated with allergic conditions or parasitic infections, not chronic bronchitis. In summary, the increased red blood cells in chronic bronchitis help enhance oxygen-carrying capacity, distinguishing it from the other options.
The nurse is assessing the patient with influenza. The patient reports having general malaise and aching muscles over the past 2 weeks. The nurse suspects that the patient may have developed which complication of influenza?
- A. Bronchitis
- B. Bacterial pneumonia
- C. Urinary infection
- D. Encephalitis
Correct Answer: B
Rationale: The correct answer is B: Bacterial pneumonia. Influenza can weaken the immune system, making the patient more susceptible to secondary bacterial infections like pneumonia. Symptoms of bacterial pneumonia, such as persistent cough, chest pain, and difficulty breathing, align with the patient's reported general malaise and muscle aches. Bronchitis (A) is a common complication of influenza but is usually characterized by cough with or without phlegm. Urinary infection (C) and encephalitis (D) are less likely in this scenario as the patient's symptoms are more indicative of a respiratory complication.
A 10 percent increase in the level of carbon dioxide in the blood will
- A. decrease the rate of breathing
- B. double the respiratory rate
- C. decrease pulmonary ventilation
- D. decrease the alveolar ventilation rate
Correct Answer: B
Rationale: A 10% increase in CO2 levels triggers chemoreceptors to signal the brainstem, increasing the respiratory rate to eliminate excess CO2. This is known as hypercapnia-induced hyperventilation. Option A is incorrect because an increase in CO2 levels would not decrease the rate of breathing. Option C is incorrect because an increase in CO2 would actually stimulate an increase in pulmonary ventilation to remove the excess CO2. Option D is incorrect because alveolar ventilation (gas exchange in the lungs) would increase, not decrease, to maintain proper oxygen and CO2 levels in the body.
Partial pressure of oxygen in the inspired and expired air is respectively
- A. 158 and 116 mm Hg
- B. 158 and 40 mm Hg
- C. 100 and 95 mm Hg
- D. 40 and 95 mm hg
Correct Answer: A
Rationale: The correct answer is A (158 and 116 mm Hg) because in inspired air, the partial pressure of oxygen is around 158 mm Hg, which corresponds to the atmospheric oxygen level. During expiration, some oxygen is exchanged for carbon dioxide, leading to a decrease in oxygen partial pressure to around 116 mm Hg.
Choice B is incorrect because the partial pressure of oxygen in expired air is not as high as 40 mm Hg, which is too low for the oxygen content in the air we breathe.
Choice C is incorrect because the partial pressure of oxygen in inspired air is not exactly 100 mm Hg, and the partial pressure in expired air is not as close to 95 mm Hg.
Choice D is incorrect because the partial pressure of oxygen in inspired air is not as low as 40 mm Hg, and the partial pressure in expired air is not as high as 95 mm Hg.
What is the main goal of treatment in heart failure?
- A. To increase blood pressure
- B. To cure the underlying cause
- C. To relieve symptoms and improve quality of life
- D. To induce weight loss
Correct Answer: C
Rationale: The correct answer is C: To relieve symptoms and improve quality of life. The main goal of treatment in heart failure is to manage symptoms, improve heart function, and enhance quality of life. This involves optimizing medications, lifestyle modifications, and sometimes devices or surgeries. Increasing blood pressure (A) is not the goal as high blood pressure can worsen heart failure. Curing the underlying cause (B) may not always be possible, so the focus is on managing symptoms. Inducing weight loss (D) may be necessary in some cases, but it is not the primary goal of treatment for heart failure.