Nokea
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?
- A. Document the findings.
- B. Administer oxygen therapy.
- C. Position the client in high-Fowler position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct action is to document the findings first because the harsh hollow sound over the trachea and larynx could indicate a potential issue with the airway or respiratory function. Documenting the findings allows for accurate communication with other healthcare providers and helps track changes in the client's condition. Administering oxygen therapy or albuterol should not be done without further assessment or orders from a healthcare provider. Positioning the client in high-Fowler position may not be the priority until a more thorough assessment is completed.
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Which of the following is NOT found in lung tissue?
- A. blood capillaries
- B. alveolar sacs
- C. interstitial fluid
- D. muscle
Correct Answer: D
Rationale: The correct answer is D: muscle. Lung tissue does not contain muscle tissue; instead, it is primarily composed of alveolar sacs for gas exchange, blood capillaries for oxygen exchange, and interstitial fluid for support. Muscles are not part of the structure of the lungs as they are not involved in the respiratory process. In summary, muscles are not found in lung tissue, making option D the correct choice.
O2 dissociation curve shift to R) by all of the following except
- A. Increase [H+]
- B. pCO2
- C. Increase temperature
- D. Carbon monoxide
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide. Carbon monoxide does not shift the O2 dissociation curve to the right (R) because it binds to hemoglobin with a higher affinity than oxygen, causing a leftward shift (L). Increased [H+], pCO2, and temperature all shift the curve to the right by decreasing hemoglobin's affinity for oxygen.
A female adult client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
- A. 15 to 60 seconds.
- B. 5 to 20 minutes.
- C. 30 to 40 minutes.
- D. 45 to 60 minutes.
Correct Answer: B
Rationale: The correct answer is B: 5 to 20 minutes. Plugging the tracheostomy tube for this duration allows the client to gradually adapt to breathing without the assistance of the tube. Initially, the client may experience increased respiratory effort, which helps improve lung function. Plugging the tube for too short a time (A) may not provide enough challenge for the client, while plugging it for too long (C, D) may cause distress or potential complications due to lack of oxygen. Therefore, the optimal time frame of 5 to 20 minutes ensures a safe and effective weaning process for the client.
When the diaphragm and external intercostals muscles contract, which of the following actions does NOT occur?
- A. air moves into the lung
- B. the intrapleural pressure increases
- C. the diaphragm moves inferiorly
- D. the intrapulmonary pressure decreases
Correct Answer: B
Rationale: When the diaphragm and external intercostals contract, the thoracic cavity expands, causing the lungs to expand and the intrapulmonary pressure to decrease (choice D). This decrease in pressure allows air to flow into the lungs (choice A). The diaphragm moves inferiorly during contraction, not superiorly (choice C). The intrapleural pressure actually decreases when these muscles contract, not increases, due to increased thoracic volume and decreased intrapleural pressure acting as a suction to keep the lungs inflated (choice B). Therefore, the correct answer is B, as the intrapleural pressure actually decreases when the diaphragm and external intercostals contract.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
- A. Inform the physician.
- B. Continue to monitor the client.
- C. Reinforce the occlusive dressing.
- D. Encourage the client to deep breathe.
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. Fluctuation of fluid level in the water seal chamber post chest tube insertion indicates proper functioning of the chest tube system. This signifies that the tube is effectively draining fluid or air from the pleural space. It is essential to continue monitoring the client to ensure ongoing proper functioning of the chest tube. Informing the physician (Choice A) is not necessary at this point unless there are other concerning symptoms. Reinforcing the occlusive dressing (Choice C) is not indicated unless there is a leak or issue with the dressing. Encouraging the client to deep breathe (Choice D) is unrelated to the assessment of the chest tube system.