Nokea
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage
- A. a headache
- B. and difficulty with vision. What action would the nurse take next?
- C. Collect the nasal drainage on a piece of filter paper.
- D. Encourage the client to blow his or her nose.
Correct Answer: A
Rationale: The correct answer is A: a headache. Nasal drainage with a nasal fracture can indicate a potential cerebrospinal fluid leak, leading to a headache. This symptom requires immediate attention to rule out serious complications. Choice B is incorrect because difficulty with vision is not typically associated with a nasal fracture. Choice C is incorrect as collecting drainage on filter paper does not address the client's symptoms. Choice D is incorrect as blowing the nose can exacerbate the fracture and should be avoided.
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The Hering-Breuer reflex
- A. functions to increase ventilation with changes in blood pressure
- B. alters pulmonary ventilation when the PO2 changes
- C. alters pulmonary ventilation when the PCO2 changes
- D. protects the lungs from damage due to overinflation
Correct Answer: D
Rationale: The correct answer is D because the Hering-Breuer reflex is a protective mechanism that prevents lung damage from overinflation by inhibiting inspiration. When the lungs are at risk of overinflation, stretch receptors in the lung tissue send signals to the brainstem to reduce or stop inspiration, preventing excessive stretching of the alveoli. Choices A, B, and C are incorrect as the Hering-Breuer reflex is not involved in changes in blood pressure, PO2, or PCO2 regulation.
Which of the following are risk factors of laryngeal cancer?
- A. Acute laryngitis
- B. Tobacco use
- C. Caffeine use
- D. Sleep apnea
Correct Answer: B
Rationale: The correct answer is B. Tobacco use is a well-established risk factor for laryngeal cancer. A (acute laryngitis) is a temporary condition and not a risk factor. C (caffeine use) has no proven link to laryngeal cancer. D (sleep apnea) is unrelated.
The client with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which action is appropriate to delegate to the experienced LPN/LVN under your supervision?
- A. Observe how well the client performs pursed-lip breathing.
- B. Plan a nursing care regimen that gradually increases activity tolerance.
- C. Assist the client with basic activities of daily living (ADLs).
- D. Consult with physical therapy about reconditioning exercises.
Correct Answer: C
Rationale: The correct answer is C. Assisting with ADLs is a routine task suitable for an LPN/LVN. Observing pursed-lip breathing (A) and planning care regimens (B) are more advanced tasks. Consulting physical therapy (D) requires RN-level decision-making.
A medical patient rings her call bell and expresses alarm to the nurse, stating, 'I've just coughed up this blood. That can't be good, can it?' How can the nurse best determine whether the source of the blood was the patient's lungs?
- A. Obtain a sample and test the pH of the blood, if possible.
- B. Try to see if the blood is frothy or mixed with mucus.
- C. Perform oral suctioning to see if blood is obtained.
- D. Swab the back of the patient's throat to see if blood is present.
Correct Answer: B
Rationale: The correct answer is B: Try to see if the blood is frothy or mixed with mucus. By observing if the blood is frothy or mixed with mucus, the nurse can determine if the source is more likely to be from the lungs, as blood from the lungs is often frothy due to air mixing with it during coughing. This observation helps differentiate between blood coming from the respiratory tract versus other sources in the body.
Incorrect choices:
A: Testing the pH of the blood does not directly indicate the source of the blood in this context.
C: Performing oral suctioning may not provide accurate information about the source of the blood.
D: Swabbing the back of the throat may not help determine if the blood is coming from the lungs as it could be from other sources in the upper respiratory tract.
The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which assessment finding indicates a potential complication and requires the nurse's immediate attention?
- A. Distended neck veins
- B. Left lower quadrant tenderness
- C. Urinary output of 40 mL/hr
- D. Excessive coughing
Correct Answer: A
Rationale: The correct answer is A: Distended neck veins. This finding indicates potential right-sided heart failure, a complication of COPD called cor pulmonale. The nurse should address this immediately to prevent further deterioration. Distended neck veins suggest increased central venous pressure and impaired right heart function. Left lower quadrant tenderness (B) is unrelated to COPD. Urinary output of 40 mL/hr (C) is within normal range. Excessive coughing (D) is a common symptom of COPD but does not indicate an immediate complication.