Nokea
A nurse is providing care after auscultating a client's breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: The correct answer is C because wheezes indicate narrowing of airways, requiring bronchodilation. Step 1: Identify the assessment finding (wheezes). Step 2: Understand that wheezes indicate airway constriction. Step 3: Appropriately intervene by administering a bronchodilator to dilate the airways and improve breathing. Other choices are incorrect because: A: Increasing oxygen flow rate does not address airway constriction. B: Encouraging coughing for crackles does not address airway narrowing. D: Deep breathing for vesicular sounds does not target airway constriction.
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Which one is a Non-reversible pulmonary disease in which the bronchi are blocked with mucous and infection and rupture of alveoli
- A. Silicosis
- B. Asphyxia
- C. Emphysema
- D. Embolism
Correct Answer: C
Rationale: Emphysema is the correct answer because it is a non-reversible pulmonary disease characterized by the destruction of lung tissue, leading to the blockage of bronchioles and rupture of alveoli. This results in difficulty breathing and reduced oxygen exchange. Silicosis (A) is caused by inhaling silica dust, not related to bronchial blockage. Asphyxia (B) is a condition of suffocation, not related to pulmonary disease. Embolism (D) is the blockage of a blood vessel by a clot, not specific to the bronchi or alveoli.
Which information from a client helps the nurse confirm the previous diagnosis of chronic stable angina?
- A. The pain wakes me up at night.
- B. The pain is level 3 to 5 (0 to 10 scale).
- C. The pain has gotten worse over the last week.
- D. The pain goes away after I stop jogging.
Correct Answer: D
Rationale: The correct answer is D because chronic stable angina is characterized by chest pain or discomfort that is triggered by physical exertion or emotional stress and relieved by rest or medication. Therefore, the fact that the pain goes away after stopping jogging aligns with the typical pattern of chronic stable angina.
A: The pain waking the client up at night is more indicative of unstable angina or a heart attack.
B: The level of pain on a scale does not provide conclusive evidence of chronic stable angina.
C: Pain worsening over time may suggest unstable angina or a heart attack rather than chronic stable angina.
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause:40:40H272:382:422:412:402:422:402:38
- A. Nasal congestion
- B. Nervousness
- C. Lethargy
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Nervousness. Albuterol sulfate is a bronchodilator commonly used to treat asthma. It works by relaxing the muscles in the airways, making it easier to breathe. Nervousness is a common side effect of albuterol due to its stimulant properties. Nasal congestion (Choice A) is not a typical side effect of albuterol. Lethargy (Choice C) is also not a common side effect, as albuterol typically has a stimulating effect. Hyperkalemia (Choice D) is not associated with albuterol use.
A nurse is assessing clients on a rehabilitation unit. Which client is not at risk for airway loss related to aspirated oral and nasopharyngeal secretions?
- A. A 24 year old with a traumatic brain injury
- B. A 36 year old who fractured his left femur
- C. A 58 year old getting radiation therapy
- D. A 66 year old who is a quadriplegic
Correct Answer: B
Rationale: The correct answer is B, a 36-year-old who fractured his left femur. This client is not at risk for airway loss related to aspirated secretions because a femur fracture does not directly impact the airway or swallowing function. Traumatic brain injury (choice A), radiation therapy (choice C), and quadriplegia (choice D) can all impair the client's ability to protect their airway and increase the risk of aspirating secretions. Therefore, these clients are at higher risk compared to the client with a femur fracture.
cochlea's have how many fluid filled chamber?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: The cochlea has 3 fluid-filled chambers: the scala vestibuli, scala media, and scala tympani. These chambers are essential for hearing as they contain different fluids (perilymph and endolymph) that help transmit sound vibrations. Choice A (1 chamber) is incorrect as the cochlea has multiple distinct chambers. Choice B (2 chambers) is incorrect as it does not accurately reflect the anatomical structure of the cochlea. Choice D (4 chambers) is incorrect as the cochlea typically consists of 3 chambers, not 4. Therefore, the correct answer is C (3 chambers) based on the accurate anatomical structure of the cochlea.