Nokea
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
- A. Administer an albuterol treatment.
- B. Notify the Rapid Response Team.
- C. Assess the client's peripheral pulses.
- D. Obtain blood and sputum cultures.
Correct Answer: B
Rationale: The correct answer is B: Notify the Rapid Response Team. Continuous cyanosis despite oxygen therapy following benzocaine administration may indicate methemoglobinemia, a serious adverse effect. Rapid Response Team should be alerted for immediate intervention and monitoring. Albuterol treatment (A) would not address methemoglobinemia. Assessing peripheral pulses (C) may not provide immediate assistance. Obtaining blood and sputum cultures (D) is not the priority in this situation.
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The 75-year-old patient asks the nurse if the Pneumovax immunization he took when he was 65 is still protecting him. Which reply is most accurate?
- A. Pneumovax protects you for your lifetime.
- B. Immunity afforded you by Pneumovax lasts only 2 years.
- C. Pneumovax protection varies according to your risk factors and living situation.
- D. After 6 years, you need a repeat dose of Pneumovax for full immunity.
Correct Answer: D
Rationale: Step 1: Pneumovax is recommended for adults aged 65 and older.
Step 2: Immunity from Pneumovax decreases over time.
Step 3: CDC recommends a second dose of Pneumovax after 5 years for those at highest risk.
Step 4: Answer D is correct as it aligns with CDC guidelines for revaccination.
Step 5: Other choices are incorrect as they do not reflect current recommendations or scientific evidence.
The normal rate and depth of breathing is established by the ________ center(s).
- A. apneustic
- B. pneumotaxic
- C. DRG and VRG
- D. expiratory
Correct Answer: C
Rationale: The correct answer is C because the Dorsal Respiratory Group (DRG) and Ventral Respiratory Group (VRG) are the centers in the brainstem responsible for controlling the rate and depth of breathing. The DRG primarily regulates inspiration, while the VRG is involved in both inspiration and expiration. The apneustic and pneumotaxic centers (choices A and B) are subregions within the pons that modulate the activity of the DRG and VRG but do not establish the baseline rate and depth of breathing. The expiratory center (choice D) is responsible for controlling only the expiratory phase of breathing and is not involved in setting the normal rate and depth of breathing.
Inhibition of medulla oblongata chemoreceptors and respiratory muscles has what effect on respiratory rate, elimination of CO2 at alveoli, and arterial PCO2?
- A. increased respiratory rate, increased elimination of CO2 at alveoli, and increased arterial
PCO2 - B. increased respiratory rate, decreased elimination of CO2 at alveoli, and decreased arterial
PCO2 - C. increased respiratory rate, increased elimination of CO2 at alveoli, and decreased arterial
PCO2 - D. decreased respiratory rate, decreased elimination of CO2 at alveoli, and increased arterial
PCO2
Correct Answer: D
Rationale: The correct answer is D. Inhibition of medulla oblongata chemoreceptors and respiratory muscles would decrease respiratory rate, leading to decreased elimination of CO2 at alveoli. This would cause an increase in arterial PCO2 due to less CO2 being removed from the body. Therefore, choice D is correct.
Choices A, B, and C are incorrect because they do not align with the physiological effects of inhibiting the medulla oblongata chemoreceptors and respiratory muscles. Option A suggests an increase in respiratory rate and elimination of CO2, which goes against the expected decrease in these parameters. Option B proposes an increase in respiratory rate but a decrease in CO2 elimination and arterial PCO2, which is inconsistent with the expected outcomes. Option C suggests an increase in respiratory rate and CO2 elimination but a decrease in arterial PCO2, which does not follow the logic of the question.
Spirometry can measure all except
- A. IC
- B. ERV
- C. FRC
- D. Vital capacity
Correct Answer: C
Rationale: Spirometry measures lung volumes and capacities. Functional Residual Capacity (FRC) is the volume of air left in the lungs after a normal exhalation, which cannot be directly measured by spirometry. Therefore, C is correct. IC (Inspiratory Capacity) is the maximum volume of air that can be inhaled after a normal exhalation, ERV (Expiratory Reserve Volume) is the additional volume of air that can be exhaled after a normal exhalation, and Vital Capacity is the total volume of air that can be exhaled after a maximum inhalation, all of which can be measured using spirometry.
Hypoxia
- A. causes hyperventilation
- B. may cause headaches, nausea, and lethargy.
- C. can lead to loss of consciousness and death
- D. all of the above
Correct Answer: D
Rationale: The correct answer is D because hypoxia, which is a condition of low oxygen levels in the body, can indeed lead to hyperventilation, as the body tries to compensate. It can also cause symptoms like headaches, nausea, and lethargy due to the lack of oxygen reaching the brain and other organs. Severe hypoxia can lead to loss of consciousness and even death if oxygen levels are not restored promptly. Therefore, all the statements in choices A, B, and C are true in relation to hypoxia, making option D the correct choice.