Nokea
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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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.
Carina is the point where ...... divided
- A. Trachea
- B. bronchi
- C. larynx
- D. none of them
Correct Answer: A
Rationale: The correct answer is A: Trachea. Carina is the point where the trachea is divided into the left and right primary bronchi. This anatomical landmark is located at the lower end of the trachea where it bifurcates into the bronchi. The other choices, B: bronchi and C: larynx, are incorrect because the trachea is the structure that is divided at the carina, not the bronchi or larynx. Choice D: none of them is also incorrect because the trachea is indeed divided at the carina. Therefore, the correct answer is A as it accurately describes the anatomical location where the trachea divides.
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.
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 pressure remains negative throughout the respiratory cycle?
- A. intrapulmonary
- B. intrapleural
- C. intra-alveolar
- D. atmospheric
Correct Answer: B
Rationale: The correct answer is B: intrapleural pressure. Intrapleural pressure remains negative throughout the respiratory cycle due to the opposing forces of the elastic recoil of the lungs and the chest wall. This negative pressure keeps the lungs inflated and facilitates breathing. In contrast, intrapulmonary (A) and intra-alveolar (C) pressures fluctuate during inhalation and exhalation, becoming positive and negative, respectively. Atmospheric pressure (D) remains relatively constant and serves as the reference point for pressure changes in the respiratory system.