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A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration?
- A. Tilt the head back as far as possible when swallowing.
- B. Swallow twice while bearing down.
- C. Breathe slowly and deeply while swallowing.
- D. Keep the head very still and straight while swallowing.
Correct Answer: B
Rationale: The correct answer is B: Swallow twice while bearing down. This technique helps close the trachea during swallowing to prevent aspiration. Swallowing twice initiates a double swallow, which helps clear the throat and reduce the risk of food or liquid entering the airway. Tilt the head back (A), breathing slowly and deeply (C), and keeping the head still and straight (D) do not directly address the risk of aspiration in a client with a supraglottic laryngectomy.
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Palpation is the assessment technique used to find which abnormal assessment findings?
- A. Stridor
- B. Finger clubbing
- C. Tracheal deviation
- D. Limited chest expansion
Correct Answer: D
Rationale: The correct answer is D because limited chest expansion is one of the abnormal assessment findings that can be identified through palpation techniques.
For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
- A. Encouraging the patient to drink three glasses of fluid daily.
- B. Keeping the patient in semi-Fowler's position.
- C. Using a high-flow venturi mask to deliver oxygen as prescribed.
- D. Administering a sedative, as prescribed.
Correct Answer: C
Rationale: The correct answer is C: Using a high-flow venturi mask to deliver oxygen as prescribed. This is the best option as it directly addresses the issue of promoting adequate gas exchange in a patient with advanced COPD. The high-flow venturi mask delivers oxygen at a precise concentration, ensuring optimal oxygenation.
Encouraging the patient to drink fluids (A) is important for overall health but does not directly address gas exchange. Keeping the patient in semi-Fowler's position (B) can help with breathing but is not as effective as providing supplemental oxygen. Administering a sedative (D) can further depress the respiratory system and worsen gas exchange, making it an inappropriate choice.
Which of the following structures is not part of the bronchial tree?
- A. alveoli
- B. bronchi
- C. terminal bronchioles
- D. respiratory bronchioles
Correct Answer: A
Rationale: The correct answer is A: alveoli. The alveoli are not part of the bronchial tree; they are the tiny air sacs at the end of the bronchial tree where gas exchange occurs. The bronchial tree consists of the bronchi, terminal bronchioles, and respiratory bronchioles, which are responsible for conducting air into the lungs. Alveoli are located at the end of the respiratory bronchioles and are where oxygen is absorbed into the bloodstream and carbon dioxide is released. Therefore, alveoli are not considered part of the bronchial tree.
What does the nurse include when planning for postural drainage for the patient with COPD?
- A. Schedules the procedure 1 hour before and after meals
- B. Has the patient cough before positioning to clear the lungs
- C. Assesses the patient’s tolerance for dependent (head-down) positions
- D. Ensures that percussion and vibration are performed before positioning the patient
Correct Answer: C
Rationale: When planning for postural drainage for a patient with COPD, assessing the patient's tolerance for dependent positions is crucial as it helps ensure the safety and effectiveness of the procedure. Positioning the patient appropriately is key in promoting drainage and improving respiratory function.
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.