Nokea
A nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following positions will the nurse instruct the client to assume?
- A. Side-lying in bed.
- B. Sitting in a recliner chair.
- C. Sitting up in bed.
- D. Sitting on the side of the bed and leaning on an overbed table.
Correct Answer: D
Rationale: The correct answer is D, sitting on the side of the bed and leaning on an overbed table. This position promotes maximum expansion of the thorax, allowing for improved lung ventilation. Leaning forward helps reduce the work of breathing and facilitates better airflow. Options A and C do not provide the same level of thoracic expansion and may not be as effective. Option B may not provide the necessary support for the client to lean forward and optimize breathing.
You may also like to solve these questions
Which phrase is used to describe the volume of air inspired and expired with a normal breath?
- A. Total lung capacity
- B. Forced vital capacity
- C. Tidal volume
- D. Residual volume
Correct Answer: C
Rationale: The correct answer is C: Tidal volume. Tidal volume refers to the volume of air inspired and expired during a normal breath. It represents the amount of air moved into or out of the lungs during each respiratory cycle, which typically ranges from 500 to 700 milliliters in adults. Total lung capacity (A) is the maximum volume of air the lungs can hold, including residual volume. Forced vital capacity (B) is the maximum amount of air that can be forcefully exhaled after a maximum inhalation, not related to a normal breath. Residual volume (D) is the volume of air remaining in the lungs after a maximal exhalation and is not part of a normal breath cycle.
Which action should the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new client?
- A. Deflate the BP cuff at a rate of 30 mm Hg per second.
- B. Have the client sit in a chair with the feet flat on the floor.
- C. Assist the client to the supine position for BP measurements.
- D. Obtain two BP readings in the dominant arm and average the results.
Correct Answer: B
Rationale: The correct answer is B because having the client sit in a chair with feet flat on the floor is the recommended position for accurate baseline BP measurement. This position ensures proper alignment of the heart and the cuff, reducing errors caused by arm positioning. Choice A is incorrect as deflating the cuff at a rate of 30 mm Hg per second is not related to obtaining an accurate baseline BP measurement. Choice C is incorrect as measuring BP in the supine position can lead to inaccurate readings due to changes in blood flow dynamics. Choice D is incorrect as obtaining two BP readings in the dominant arm and averaging the results may not provide an accurate baseline BP measurement due to variations in BP readings between arms.
The client with which of the following types of lung cancer metastasizes quickly?
- A. Adenocarcinoma
- B. Oat cell
- C. Squamous cell
- D. Bronchial carcinoids
Correct Answer: B
Rationale: The correct answer is B: Oat cell. Oat cell (small cell) lung cancer metastasizes quickly due to its aggressive nature, high growth rate, and early dissemination to distant sites. This type of cancer is known for its rapid spread to other organs, leading to poor prognosis. Adenocarcinoma, squamous cell, and bronchial carcinoids have a slower metastatic rate compared to oat cell lung cancer. Adenocarcinoma tends to metastasize to the lymph nodes and other organs over time, while squamous cell typically spreads locally within the lung tissue. Bronchial carcinoids are slow-growing tumors with a lower propensity for rapid metastasis compared to oat cell lung cancer.
Regarding oxygen transport
- A. The predominant way oxygen is transported in the blood is as dissolved oxygen
- B. 1 gram of pure Hb can combine with 1.34 - 1.39 ml of oxygen
- C. An anaemic patient has a lowered arterial pO2 because the Hb is low
- D. CO2 is 200 times more soluble than oxygen
Correct Answer: B
Rationale: The correct answer is B: 1 gram of pure Hb can combine with 1.34 - 1.39 ml of oxygen. This is correct because each gram of hemoglobin can bind with approximately 1.34 - 1.39 ml of oxygen, facilitating efficient oxygen transport in the blood.
A is incorrect because while a small amount of oxygen is transported as dissolved oxygen, the majority is transported bound to hemoglobin.
C is incorrect because arterial pO2 reflects the oxygen content in the blood, not just the hemoglobin levels.
D is incorrect because CO2 is actually 20 times more soluble than oxygen, not 200 times.
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?
- A. Call the primary health care provider and request food and water for the client.
- B. Provide the client with ice chips instead of a drink of water.
- C. Assess the client's gag reflex before giving any food or water.
- D. Let the client have a small sip to see whether he or she can swallow.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's gag reflex before giving any food or water. After a bronchoscopy, the client's gag reflex may be compromised, increasing the risk of aspiration. Assessing the gag reflex is crucial to ensure the client can safely swallow without the risk of choking or aspirating. This step is essential before providing any food or water to prevent potential complications.
Incorrect Choices:
A: Calling the primary health care provider for food and water is unnecessary as the nurse can make this decision based on assessment.
B: Providing ice chips instead of water does not address the need for assessing the gag reflex before giving any form of intake.
D: Letting the client have a small sip without assessing the gag reflex first can pose a risk of aspiration if the reflex is impaired.