Nokea
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60 pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?
- A. Tell the client that he needs to quit smoking to stop further cancer development.
- B. Encourage the client to be completely honest about both tobacco and marijuana use.
- C. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
- D. Avoid giving the client false hope regarding cancer treatment and prognosis.
Correct Answer: C
Rationale: Rationale:
C is correct as maintaining a nonjudgmental attitude is crucial to establish trust and rapport with the client. It helps the client feel comfortable sharing information, leading to better assessment and care. A is incorrect as quitting smoking may not be the immediate priority. B is incorrect as honesty about marijuana use is not the primary concern. D is incorrect as it does not address the importance of establishing a therapeutic relationship.
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The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?
- A. Urine output is 500 mL during an 8-hour shift.
- B. Tremors are noted in the fingers when the patient extends the arms.
- C. The client reports a headache with pain at level 7
- D. The client cannot move the left arm when asked to do so.
Correct Answer: D
Rationale: The correct answer is D because the inability to move the left arm could indicate a neurological deficit or stroke, which is a critical finding that requires immediate medical attention in a hypertensive emergency. This could indicate a potential life-threatening condition that needs urgent intervention to prevent further complications.
A: Urine output is important but not as critical as potential neurological deficits in this scenario.
B: Tremors in the fingers are concerning but not as urgent as a potential neurological deficit.
C: Headache at level 7 is significant but not as critical as a neurological deficit that could indicate a stroke.
For a male client with an endotracheal (ET) tube, which nursing action is most essential?
- A. Auscultating the lungs for bilateral breath sounds.
- B. Turning the client from side to side every 2 hours.
- C. Monitoring serial blood gas values every 4 hours.
- D. Providing frequent oral hygiene.
Correct Answer: A
Rationale: The correct answer is A: Auscultating the lungs for bilateral breath sounds. This is the most essential nursing action for a male client with an endotracheal tube because it ensures proper placement of the tube and adequate ventilation. By auscultating the lungs, the nurse can assess for any potential complications such as tube displacement, pneumothorax, or mucus plugging. This action helps in early detection of respiratory issues and prompt intervention if needed.
Summary:
- Choice B (Turning the client from side to side every 2 hours) is important for preventing pressure ulcers but not as critical as assessing breath sounds.
- Choice C (Monitoring serial blood gas values every 4 hours) is important for evaluating respiratory status but does not provide immediate information on tube placement.
- Choice D (Providing frequent oral hygiene) is important for preventing infections but does not directly assess the client's respiratory status with an ET tube.
In an older client, the alveolar walls become thinner and contain fewer capillaries. What does this condition lead to?
- A. Loss of elasticity in the lungs
- B. Decreased gas exchange
- C. Increased stiffness in lungs
- D. Decreased numbers of alveoli
Correct Answer: B
Rationale: The correct answer is B (Decreased gas exchange). Thinning alveolar walls and reduced capillary density directly impair the diffusion of gases across the alveolar-capillary membrane, leading to decreased gas exchange. While A (loss of elasticity) might occur with aging, it is not the primary consequence here. C (increased stiffness) is incorrect because stiffness typically results from fibrosis or other conditions, not thinning walls. D (decreased numbers of alveoli) could happen but is unrelated to the specific scenario described.
During inspiration, air passes into lungs due to
- A. Increase in volume of thoracic cavity and fall in lung pressure
- B. Fall in pressure inside the lungs
- C. Increased volume of thoracic cavity
- D. Muscular expansion of lungs
Correct Answer: A
Rationale: Correct Answer: A - Increase in volume of thoracic cavity and fall in lung pressure
Rationale:
1. During inspiration, the diaphragm contracts and moves downward, increasing the volume of the thoracic cavity.
2. The external intercostal muscles also contract, lifting the ribcage and further expanding the thoracic cavity.
3. As thoracic cavity volume increases, lung pressure decreases, creating a pressure gradient that allows air to flow into the lungs.
Summary:
B: Fall in pressure inside the lungs - This is a consequence of the increase in thoracic cavity volume, not the cause of air entering the lungs.
C: Increased volume of thoracic cavity - This is correct but does not explain how air enters the lungs.
D: Muscular expansion of lungs - Lungs do not expand on their own; it is the thoracic cavity that expands to create the pressure gradient for air entry.
What is the proper sequence in the flow of air in humans?
- A. nasal cavities, larynx, pharynx, bronchi, trachea
- B. nasal cavities, pharynx, bronchi, larynx, trachea
- C. nasal cavities, pharynx, larynx, trachea, bronchi
- D. nasal cavities, larynx, pharynx, trachea, bronchi
Correct Answer: C
Rationale: The correct sequence is C: nasal cavities, pharynx, larynx, trachea, bronchi. Air enters through the nasal cavities, passes through the pharynx, then the larynx where the vocal cords are located, then enters the trachea, and finally branches into the bronchi leading to the lungs. This sequence follows the anatomical pathway of the respiratory system, ensuring proper filtration, warming, and humidification of the air. Choices A, B, and D have incorrect sequences that do not follow the anatomical order of the respiratory pathway, leading to an inaccurate flow of air in humans.