Nokea
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?
- A. Assess the client's pain level.
- B. Keep the client's head elevated.
- C. Teach the client about the causes of nasal bleeding.
- D. Assess the client's airway.
Correct Answer: D
Rationale: The correct answer is D: Assess the client's airway. This is the priority action as airway patency is always the top priority in any emergency situation. In this case, posterior nasal bleeding can lead to blood flow into the throat, potentially obstructing the airway. Ensuring the client's airway is clear and maintaining adequate oxygenation is crucial for their safety.
Choice A (Assess the client's pain level) is not the priority when there is a potential risk to the airway. Choice B (Keep the client's head elevated) may be done after confirming airway patency. Choice C (Teach the client about the causes of nasal bleeding) is important but not the immediate priority in this situation.
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Which of the following does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Friction rub
- C. Expiratory wheezes
- D. Fluid in the involved area
Correct Answer: D
Rationale: The correct answer is D. Fluid in the pleural space muffles breath sounds and may be noted during auscultation. A (pronounced breath sounds) is incorrect as they are diminished in pleural effusion. B (friction rub) occurs in pleuritis, not effusion. C (expiratory wheezes) indicates airway obstruction, not fluid accumulation.
What is the proper sequence in the flow of air in humans?
- A. nasal cavities, larynx, pharynx, bronchi, trachea
- B. nasal cavities, pharynx, bronchi, larynx, trachea
- C. nasal cavities, pharynx, larynx, trachea, bronchi
- D. nasal cavities, larynx, pharynx, trachea, bronchi
Correct Answer: C
Rationale: The correct sequence is C: nasal cavities, pharynx, larynx, trachea, bronchi. Air enters through the nasal cavities, passes through the pharynx, then the larynx where the vocal cords are located, then enters the trachea, and finally branches into the bronchi leading to the lungs. This sequence follows the anatomical pathway of the respiratory system, ensuring proper filtration, warming, and humidification of the air. Choices A, B, and D have incorrect sequences that do not follow the anatomical order of the respiratory pathway, leading to an inaccurate flow of air in humans.
In an older client, the alveolar walls become thinner and contain fewer capillaries. What does this condition lead to?
- A. Loss of elasticity in the lungs
- B. Decreased gas exchange
- C. Increased stiffness in lungs
- D. Decreased numbers of alveoli
Correct Answer: B
Rationale: The correct answer is B (Decreased gas exchange). Thinning alveolar walls and reduced capillary density directly impair the diffusion of gases across the alveolar-capillary membrane, leading to decreased gas exchange. While A (loss of elasticity) might occur with aging, it is not the primary consequence here. C (increased stiffness) is incorrect because stiffness typically results from fibrosis or other conditions, not thinning walls. D (decreased numbers of alveoli) could happen but is unrelated to the specific scenario described.
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
- A. Administer prescribed anxiolytic medication.
- B. Ensure that informed consent is on the chart.
- C. Reinforce any teaching done previously.
- D. Start the preoperative antibiotic infusion.
Correct Answer: B
Rationale: The correct answer is B: Ensure that informed consent is on the chart. This is the priority action because obtaining informed consent is essential before any procedure to ensure that the client understands the risks, benefits, and alternatives. Administering anxiolytic medication (A) may be necessary but is not the priority. Reinforcing teaching (C) and starting antibiotics (D) are important but not as urgent as ensuring informed consent.
Internal intercostal muscles are used in ...
- A. inspiration
- B. expiration
- C. both of them
- D. pause
Correct Answer: B
Rationale: The correct answer is B: expiration. The internal intercostal muscles are used during expiration to decrease the size of the thoracic cavity, increasing the pressure in the lungs, causing air to be pushed out. During inspiration, the external intercostal muscles are used to expand the thoracic cavity. Choice A is incorrect as it refers to inspiration. Choice C is incorrect because internal intercostal muscles are not involved in both inspiration and expiration simultaneously. Choice D is incorrect as there is no specific muscle action associated with a "pause" in breathing.