Nokea
A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met?
- A. Client reports pain is controlled satisfactorily with analgesic regime.
- B. Client does not have foul odor to the breath or beefy red mucus membranes.
- C. Client is able to swallow own secretions without drooling.
- D. Client's vital signs are within normal parameters.
Correct Answer: C
Rationale: Rationale:
The correct answer is C because the ability to swallow own secretions without drooling indicates that the client's airway is patent and functional post modUPPP, a priority goal for this procedure. This assessment finding ensures that the client can maintain a clear airway and prevent complications such as aspiration.
Incorrect choices:
A: Although pain control is important, it is not a priority assessment for this specific procedure.
B: Absence of foul odor or red mucus membranes is not directly related to the airway patency or swallowing ability.
D: While normal vital signs are reassuring, they do not directly indicate the success of the surgery in improving airway function.
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What is the name given to the respiratory ailment in which the bronchioles constrict severely?
- A. pleurisy
- B. emphysema
- C. bronchitis
- D. asthma
Correct Answer: D
Rationale: The correct answer is D: asthma. Asthma is a respiratory ailment characterized by severe constriction of the bronchioles due to inflammation and muscle contraction. This leads to difficulty breathing and wheezing. Pleurisy (A) is inflammation of the lining of the lungs, emphysema (B) is a long-term lung disease, and bronchitis (C) is inflammation of the bronchial tubes. Asthma specifically refers to the bronchioles constriction, making it the correct choice.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
- A. Their location over a specific area of the lung
- B. The volume of the sounds
- C. Whether they are heard on inspiration or expiration
- D. Whether or not they are continuous breath sounds
Correct Answer: A
Rationale: The correct answer is A because vesicular, bronchovesicular, and bronchial breath sounds are distinguished based on their location over specific areas of the lung. Vesicular sounds are soft and low-pitched and are heard over most of the lung fields, bronchovesicular sounds are intermediate in pitch and are heard over the major bronchi, and bronchial sounds are loud and high-pitched and are heard over the trachea and larynx. Choices B, C, and D are incorrect as the distinction between these breath sounds is not based on volume, inspiration or expiration, or continuity of the sounds.
diaphragm relaxes and decrease thoracic space in which phase of respiration.
- A. inspiration
- B. expiration
- C. Pause
- D. both a and b
Correct Answer: B
Rationale: During expiration, the diaphragm relaxes, causing it to move upwards, which decreases the thoracic space. This leads to the expulsion of air from the lungs. In contrast, during inspiration, the diaphragm contracts and moves downwards, increasing the thoracic space to allow air to enter the lungs. Option C, Pause, does not involve any specific respiratory phase. Option D, both a and b, is incorrect because during inspiration, the diaphragm contracts and increases thoracic space. Therefore, the correct answer is B, expiration, as this phase specifically involves the relaxation of the diaphragm and the decrease in thoracic space.
If his R = 0.8 how much will his arterial pO2 fall?
- A. 85mmHg
- B. 75mmHg
- C. 60mmHg
- D. 50mmHg
Correct Answer: D
Rationale: The correct answer is D (50mmHg). To calculate the fall in arterial pO2, we use the formula: Fall in pO2 = (Initial pO2) - (Initial pO2 x R). If R = 0.8, the fall in pO2 = (100mmHg) - (100mmHg x 0.8) = 100mmHg - 80mmHg = 20mmHg. Therefore, the arterial pO2 will fall by 20mmHg. Among the choices, D (50mmHg) is the closest to the calculated value of 20mmHg, making it the correct answer. Other choices (A, B, C) do not align with the calculated fall in pO2.
A client with pneumonia has a fever of 101.4° F (38.6° C) a nonproductive cough and an O2 saturation of 88%. The client is weak and needs assistance to get out of bed. Which client problem should the nurse assign as the priority?
- A. Fatigue
- B. Hyperthermia
- C. Impaired mobility
- D. Impaired gas exchange
Correct Answer: D
Rationale: The correct answer is D, Impaired gas exchange. This is the priority because the client's O2 saturation of 88% indicates poor oxygenation, which can lead to serious complications like hypoxemia. The fever and nonproductive cough are symptoms of pneumonia contributing to impaired gas exchange. Addressing this issue is crucial to prevent respiratory distress.
A: Fatigue - While important, fatigue is a secondary concern compared to impaired gas exchange, which directly affects oxygenation and can be life-threatening.
B: Hyperthermia - The client's fever is likely related to the pneumonia but managing impaired gas exchange takes precedence as it directly impacts oxygen delivery to tissues.
C: Impaired mobility - While assisting the client out of bed is necessary, the priority is to address the underlying problem of impaired gas exchange to prevent respiratory compromise.