Nokea
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond?
- A. I will consult the speech therapist to ensure you are swallowing properly.
- B. This is normal after surgery. What types of food do you like to eat?
- C. I will ask the dietitian to change the consistency of the food in your diet.
- D. Replacement of protein, calories, and water is very important after surgery.
Correct Answer: B
Rationale: Step 1: Acknowledge client's concern about bland taste.
Step 2: Validate normalcy post-laryngectomy.
Step 3: Assess client's food preferences for individualized care.
Step 4: Encourage open communication for effective care plan.
Step 5: Addressing the issue holistically promotes client-centered care.
Summary:
- A: Focuses on swallowing, not taste.
- C: Addresses food consistency, not taste.
- D: Important but not directly related to client's concern.
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The covering of the lung is called
- A. Pericardium
- B. Perichondrium
- C. Pleural membrane/ pleura
- D. Peritoneum
Correct Answer: C
Rationale: The correct answer is C: Pleural membrane/pleura. The pleural membrane is a double-layered serous membrane that covers the lungs. The visceral pleura is attached to the lung surface, while the parietal pleura lines the chest cavity. This arrangement helps reduce friction and allows the lungs to expand during breathing.
A: Pericardium covers the heart, not the lungs.
B: Perichondrium covers cartilage, not the lungs.
D: Peritoneum covers abdominal organs, not the lungs.
Therefore, the correct choice is C because it specifically refers to the covering of the lungs.
Which of the following should the nurse include in the teaching plan of a client with acute bronchitis?
- A. Not coughing frequently
- B. Consuming adequate calories
- C. Washing the hands frequently
- D. Encouraging a semi-Fowler’s position
Correct Answer: C
Rationale: The correct answer is C. Frequent handwashing prevents the spread of infection, which is crucial in managing acute bronchitis. A (not coughing frequently) is impractical and counterproductive. B (consuming adequate calories) supports general health but is not specific. D (semi-Fowler’s position) may aid breathing but is not a primary teaching point.
The surface area of the alveoli is about
- A. 80 m2
- B. 70m2
- C. 60m2
- D. 90m2
Correct Answer: A
Rationale: The correct answer is A: 80 m2. The alveoli are tiny air sacs in the lungs where gas exchange occurs. The surface area of the alveoli is crucial for efficient gas exchange. The average adult human has around 300 million alveoli with a total surface area of about 70-100 m2, making option A the most accurate. Option B, C, and D are incorrect as they do not fall within the typical range of alveolar surface area. It is important to remember the importance of the large surface area of the alveoli in facilitating the exchange of oxygen and carbon dioxide during respiration.
which of the following is a chronic respiratory disorder caused by smoking?
- A. asthma
- B. emphysema
- C. respiratory alkalosis
- D. Acidosis
Correct Answer: B
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The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that
the level of drainage has not increased over the last 3 hours. After assessing the patient’s
respiratory status, what should the nurse do next?
- A. Raise the system above the patient's heart.
- B. Check the tubing for kinks.
- C. Reposition the patient.
- D. Notify the physician.
Correct Answer: B
Rationale: The correct answer is B: Check the tubing for kinks. This is the best next step because stagnant drainage could be caused by a kink in the tubing, obstructing proper drainage. By checking for kinks, the nurse ensures proper functioning of the drainage system, preventing potential complications such as fluid buildup or infection.
Raising the system above the patient's heart (A) may not address the underlying issue of kinked tubing. Repositioning the patient (C) may not be necessary if the drainage is not related to patient positioning. Notifying the physician (D) should be done after checking the tubing for kinks, as it is important to troubleshoot and address the issue promptly.