Nokea
A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height and weight
- D. Occupation and hobbies
Correct Answer: D
Rationale: The correct answer is D: Occupation and hobbies. This is the highest priority information for the nurse to obtain because it can provide crucial insights into potential respiratory risks or exposures (e.g., smoking, exposure to fumes or pollutants). Understanding the client's occupation and hobbies helps the nurse assess the impact on respiratory health and tailor interventions accordingly.
A: Average daily fluid intake is important for overall health but not directly related to respiratory status.
B: Neck circumference may be relevant for assessing airway patency in certain conditions, but occupation and hobbies are more pertinent.
C: Height and weight are important for general health assessment but do not directly impact respiratory status as much as occupation and hobbies.
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Reduction in respiratory surface of the lungs due to break down of partition in the alveoli is known as
- A. Asphyxia
- B. Bronchitis
- C. Asthma
- D. Emphysema
Correct Answer: D
Rationale: Emphysema is the correct answer because it is a condition where the alveoli walls break down, reducing the surface area for gas exchange in the lungs. This leads to difficulty in breathing. Asphyxia is suffocation due to lack of oxygen, not related to alveoli breakdown. Bronchitis is inflammation of the bronchial tubes, not alveoli damage. Asthma is a chronic condition affecting the airways, not specifically related to alveoli destruction. Therefore, emphysema is the most appropriate term for reduction in respiratory surface due to alveolar breakdown.
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.
The partial pressure of oxygen in arterial blood is approximately
- A. 40 mm Hg
- B. 100 mm Hg
- C. 50 mm Hg
- D. 70 mm Hg
Correct Answer: B
Rationale: The correct answer is B: 100 mm Hg. In arterial blood, the partial pressure of oxygen is typically around 100 mm Hg due to the oxygen-rich environment in the lungs. This value represents the pressure exerted by oxygen molecules in the blood. Choices A, C, and D are incorrect because they do not align with the normal range of oxygen partial pressure in arterial blood, which is around 100 mm Hg. Option A is too low, option C is slightly below the normal range, and option D is slightly above the normal range. Therefore, B is the most accurate representation of the typical partial pressure of oxygen in arterial blood.
The impulse for voluntary muscles for forceful breathing starts in
- A. Medulla (Pons)
- B. Vagus nerve
- C. Cerebral hemispheres
- D. Spinal cord
Correct Answer: C
Rationale: The correct answer is C: Cerebral hemispheres. The impulse for voluntary muscles for forceful breathing originates in the cerebral hemispheres where conscious control over breathing is regulated. The cerebral cortex sends signals to the respiratory muscles to increase or decrease breathing effort based on the body's needs. The other choices are incorrect because:
A: Medulla (Pons) - This region of the brainstem is responsible for automatic breathing control, not voluntary forceful breathing.
B: Vagus nerve - The vagus nerve is not directly involved in initiating voluntary breathing movements.
D: Spinal cord - While the spinal cord plays a role in coordinating some aspects of breathing, it is not the primary center for voluntary forceful breathing control.
A client with pneumonia has a fever of 101.4° F (38.6° C) a nonproductive cough and an O2 saturation of 88%. The client is weak and needs assistance to get out of bed. Which client problem should the nurse assign as the priority?
- A. Fatigue
- B. Hyperthermia
- C. Impaired mobility
- D. Impaired gas exchange
Correct Answer: D
Rationale: The correct answer is D, Impaired gas exchange. This is the priority because the client's O2 saturation of 88% indicates poor oxygenation, which can lead to serious complications like hypoxemia. The fever and nonproductive cough are symptoms of pneumonia contributing to impaired gas exchange. Addressing this issue is crucial to prevent respiratory distress.
A: Fatigue - While important, fatigue is a secondary concern compared to impaired gas exchange, which directly affects oxygenation and can be life-threatening.
B: Hyperthermia - The client's fever is likely related to the pneumonia but managing impaired gas exchange takes precedence as it directly impacts oxygen delivery to tissues.
C: Impaired mobility - While assisting the client out of bed is necessary, the priority is to address the underlying problem of impaired gas exchange to prevent respiratory compromise.