Nokea
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?
- A. Call the operating room to inform them of a pending emergency case.
- B. No action is needed at this time; this is a normal finding in some clients.
- C. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
- D. Stay with the client and have someone else call the primary health care provider immediately.
Correct Answer: D
Rationale: The correct answer is D.
1. Pulsation of the tracheostomy tube with the heartbeat indicates a possible vascular anomaly or the tube being in contact with a major vessel.
2. Staying with the client ensures immediate monitoring and intervention if needed.
3. Having someone else call the primary health care provider promptly allows for timely assessment and intervention.
4. Options A, B, and C are incorrect. Option A is premature without assessing the client further. Option B is incorrect as pulsation is not a normal finding in tracheostomy tubes. Option C is unsafe and can lead to airway compromise.
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When you swallow, the epiglottis covers the opening to the
- A. pharynx.
- B. esophagus.
- C. larynx.
- D. bronchus.
Correct Answer: C
Rationale: The correct answer is C: larynx. When you swallow, the epiglottis covers the opening to the larynx to prevent food or liquid from entering the airway and instead directs it towards the esophagus. The epiglottis acts as a protective mechanism to ensure that food goes down the correct pathway. Choices A (pharynx), B (esophagus), and D (bronchus) are incorrect because the epiglottis does not directly cover the opening to these structures during swallowing. The epiglottis specifically functions to protect the larynx and the airway during the swallowing process.
Which of the following neurological controls of ventilation responds to changes in the pH and levels of oxygen and CO2 in the blood?
- A. Central chemoreceptors in the medulla
- B. Peripheral chemoreceptors in the aortic arch and carotid arteries
- C. Respiratory centers in the medulla oblongata and pons
- D. Central chemoreceptors in the spinal cord
Correct Answer: A
Rationale: The correct answer is A. Central chemoreceptors in the medulla are highly sensitive to changes in pH and CO2 levels, influencing respiratory rate and depth. B is incorrect because peripheral chemoreceptors respond mainly to O2 levels. C refers to general respiratory control centers, not specific chemoreceptor function. D is incorrect as the spinal cord lacks central chemoreceptors.
Which class of medications is commonly prescribed to manage symptoms and improve outcomes in heart failure?
- A. Antibiotics
- B. Antidepressants
- C. Beta-blockers
- D. Antihistamines
Correct Answer: C
Rationale: The correct answer is C: Beta-blockers. Beta-blockers are commonly prescribed in heart failure to manage symptoms and improve outcomes by reducing the heart's workload and improving its efficiency. They help lower blood pressure, decrease heart rate, and improve heart function. Antibiotics (A) are used to treat bacterial infections, not heart failure. Antidepressants (B) are used for mental health conditions, not heart failure. Antihistamines (D) are used to treat allergies, not heart failure.
The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse's postprocedure care?
- A. Assisting with pulmonary function testing (PFT)
- B. Maintaining the patient's chest tube
- C. Administering oral suction as needed
- D. Performing chest physiotherapy
Correct Answer: B
Rationale: The correct answer is B: Maintaining the patient's chest tube. After a mediastinotomy, the focus of postprocedure care is to ensure proper drainage and prevent pneumothorax. Chest tube maintenance is crucial for monitoring drainage, preventing complications, and promoting lung expansion. Assisting with PFT (A) is not a priority immediately post mediastinotomy. Administering oral suction (C) can disrupt the chest tube and increase infection risk. Performing chest physiotherapy (D) may be indicated later but is not the immediate priority.
Which teaching point is most important for the client with a peritonsillar abscess?
- A. Gargle with warm salt water.
- B. Take all antibiotics as directed.
- C. Let us know if you want liquid medications.
- D. Wash hands frequently.
Correct Answer: B
Rationale: The correct answer is B: Take all antibiotics as directed. This is the most important teaching point for a client with a peritonsillar abscess because antibiotics are crucial in treating the infection and preventing complications. Here's the rationale:
1. Antibiotics target the bacteria causing the abscess, helping to clear the infection.
2. Incomplete antibiotic course can lead to antibiotic resistance and recurrence of infection.
3. Not following antibiotic instructions can result in treatment failure and worsening of the abscess.
4. Gargling with warm salt water (choice A) may provide temporary relief but does not address the underlying infection. Liquid medications (choice C) and handwashing (choice D) are important but not as vital as completing the antibiotic course.