Nokea
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:
- A. 1 L/min
- B. 2 L/min
- C. 6 L/min
- D. 10 L/min
Correct Answer: B
Rationale: The correct answer is B: 2 L/min. The rationale is that in emphysema, high oxygen flow rates can cause oxygen toxicity. The recommended maximum flow rate for patients with emphysema is typically 2 L/min to prevent oxygen toxicity. Choice A (1 L/min) may not provide sufficient oxygen, choice C (6 L/min) and choice D (10 L/min) are too high and can lead to oxygen toxicity in patients with emphysema. Therefore, choice B is the most appropriate and safe option for this client.
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Diaphragm is supplied with Phrenic nerve and is involved in
- A. Inspiration
- B. Parturition
- C. Micturition and Defecation
- D. All these
Correct Answer: D
Rationale: The correct answer is D: All these. The phrenic nerve innervates the diaphragm, which is responsible for inspiration (A). During parturition (B), the diaphragm plays a role in the pushing phase of labor. While the diaphragm is not directly involved in micturition and defecation (C), it indirectly affects these processes by helping to create intra-abdominal pressure. Therefore, the correct answer is D as the diaphragm is involved in inspiration, parturition, and indirectly affects micturition and defecation.
A client who is human immunodeficiency virus-positive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as:
- A. Positive
- B. Negative
- C. Inconclusive
- D. Indicating the need for repeat testing.
Correct Answer: A
Rationale: The correct answer is A: Positive. In individuals with HIV, a positive Mantoux test is considered when the induration is 5 mm or greater. A 7-mm area of induration indicates a positive result, suggesting an immune response to the tuberculin antigen, potentially due to latent tuberculosis infection. The other choices are incorrect because a 7-mm induration in an HIV-positive client is not considered negative, inconclusive, or indicative of the need for repeat testing based on current guidelines.
A client has returned to the coronary care unit after having a coronary angiogram. Which assessment data indicate the need for immediate action by the nurse?
- A. Diminished pedal pulse volume
- B. Heart rate 100 beats/min
- C. Blood pressure 104/60 mm Hg
- D. Capillary refill less than 3 seconds
Correct Answer: A
Rationale: The correct answer is A: Diminished pedal pulse volume. This indicates potential circulation compromise, which can lead to ischemia or impaired tissue perfusion. Immediate action is required to prevent further complications. B: Heart rate 100 beats/min is within normal range. C: Blood pressure 104/60 mm Hg is slightly low but not critically concerning. D: Capillary refill less than 3 seconds indicates good peripheral perfusion.
What dietary recommendation is often given to heart failure patients to manage their condition?
- A. High-sodium diet
- B. Low-fat diet
- C. Low-sugar diet
- D. Low-sodium diet
Correct Answer: D
Rationale: The correct answer is D: Low-sodium diet. Sodium can exacerbate fluid retention in heart failure patients, leading to increased workload on the heart. A low-sodium diet helps reduce fluid retention and manage symptoms. High-sodium diet (A) is detrimental to heart failure patients. Low-fat diet (B) and low-sugar diet (C) may be beneficial for overall health but are not specific recommendations for managing heart failure.
Hemoglobin gives up O2 when
- A. carbon dioxide concentrations are high
- B. body temperature is lowered.
- C. pH values are high
- D. CO2 concentrations are low
Correct Answer: A
Rationale: The correct answer is A: carbon dioxide concentrations are high. When carbon dioxide levels are high, it leads to a decrease in blood pH, triggering hemoglobin to release oxygen more readily through the Bohr effect. This is a physiological response to maintain homeostasis. The other choices (B, C, D) do not directly affect the release of oxygen from hemoglobin.