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A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first?
- A. Facial pain
- B. Vital signs
- C. Bone displacement
- D. Airway patency
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Ensuring airway patency is the top priority in any client assessment, especially in cases of facial trauma like a nasal fracture. This is because compromised airway can lead to respiratory distress or failure. Assessing airway patency should always be the first step to ensure the client's ability to breathe.
Facial pain (A) may be important but does not address immediate life-threatening concerns. Vital signs (B) are important but assessing airway patency takes precedence for client safety. Bone displacement (C) is relevant but does not address the immediate need to maintain airway patency.
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When teaching the patient with mild asthma about the use of the peak flow meter, what should the nurse instruct the patient to do?
- A. a. Carry the flow meter with the patient at all times in case an asthma attack occurs
- B. b. Use the flow meter to check the status of the patient’s asthma every time the patient takes quick-relief medication
- C. c. Follow the written asthma action plan (e.g., take quick-relief medication) if the expiratory flow rate is in the yellow zone
- D. Use the flow meter by emptying the lungs, closing the mouth around the mouthpiece, and inhaling through the meter as quickly as possible
Correct Answer: C
Rationale: The nurse should instruct the patient to follow the written asthma action plan if the expiratory flow rate is in the yellow zone. This helps the patient know when to take quick-relief medication based on their peak flow meter readings.
Which intervention for airway management should you delegate to the nursing assistant?
- A. Assist client to sit up on side of bed.
- B. Instruct client to cough effectively.
- C. Teach client to use incentive spirometry.
- D. Auscultate breath sounds every 4 hours.
Correct Answer: A
Rationale: The correct answer is A. Assisting the client to sit up is a basic intervention suitable for a nursing assistant. Instructing effective coughing (B) and teaching incentive spirometry (C) require more skill. Auscultating breath sounds (D) is outside the scope of practice for a nursing assistant.
A 68-year-old male is being admitted to the hospital for an exacerbation of his COPD. The nurse is developing his plan of care. The nurse can expect that this client will?
- A. Be placed on 10 L of oxygen per nasal cannula.
- B. Be placed in respiratory isolation.
- C. Require frequent rest periods throughout the day.
- D. Be placed on fluid restriction.
Correct Answer: C
Rationale: The correct answer is C: Require frequent rest periods throughout the day. This is because patients with COPD often experience shortness of breath and fatigue, necessitating frequent rest periods to conserve energy and manage symptoms. Oxygen therapy is typically started at a lower flow rate (2-4 L/min) to avoid suppressing the patient's respiratory drive, so option A is not appropriate. Respiratory isolation is unnecessary for COPD exacerbation, as it is not a contagious condition, making option B incorrect. Fluid restriction is not typically indicated for COPD exacerbation unless the patient has comorbid conditions like heart failure, so option D is not the priority.
Higher brain centers that alter the activity of the respiratory centers include all of the following except
- A. cortical association areas
- B. the precentral motor gyrus
- C. the limbic system
- D. the hypothalamus
Correct Answer: B
Rationale: The correct answer is B: the precentral motor gyrus. This area is primarily responsible for voluntary motor control, not for altering the activity of respiratory centers. Cortical association areas (A), the limbic system (C), and the hypothalamus (D) can influence respiratory centers through emotional responses, autonomic control, and regulation of breathing patterns, respectively. The precentral motor gyrus is not directly involved in modifying respiratory activity.
Tracheal respiration is found in
- A. Insects and Millipedes
- B. Scorpion and Prawn
- C. Pila and Lobuster
- D. Starfish and Sea cucumber
Correct Answer: A
Rationale: Tracheal respiration is a type of respiration system found in insects and millipedes. This system involves the use of tracheae, which are tiny tubes that deliver oxygen directly to tissues. Insects and millipedes have evolved this efficient respiratory system to support their high metabolic rates. Scorpions and prawns (Choice B), Pila and lobsters (Choice C), and starfish and sea cucumbers (Choice D) do not have tracheal respiration systems. Therefore, the correct answer is A.