Nokea
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
- A. Expiratory wheezes
- B. Inspiratory wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: D
Rationale: The correct answer is D: Crackles. In heart failure, crackles are often heard on auscultation due to fluid accumulation in the lungs. This is a result of the heart's inability to effectively pump blood, leading to congestion in the pulmonary circulation. Crackles are discontinuous, moist sounds that occur during inspiration and sometimes expiration. Expiratory wheezes (A) are typically associated with obstructive airway diseases such as asthma. Inspiratory wheezes (B) are not commonly heard in heart failure. Rhonchi (C) are low-pitched continuous sounds often heard in patients with bronchitis or pneumonia, not specifically in heart failure.
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Which of the following nursing interventions regarding nutrition is used until the suture line heals, usually 10 to 14 days postoperatively?
- A. Enteral feedings
- B. Meticulous mouth care every 4 hours
- C. Gradual advancement of the diet
- D. Reassurance that the sense of taste will return
Correct Answer: A
Rationale: The correct answer is A. Enteral feedings bypass the oral route, allowing the suture line to heal without strain. B (meticulous mouth care) is important but not directly related to nutrition. C (gradual advancement of the diet) occurs later. D (reassurance) addresses psychological concerns but not nutritional needs.
Branches of bronchial tree
- A. primary bronchi_trachea_secondary bronchi_tertiary_bronchioles_terminal
- B. trachea-pri bronchi-sec bronchi-ter bronchi-bronchioles-terinnal
- C. Both a and b
- D. itis
Correct Answer: B
Rationale: The correct answer is B because it correctly lists the branches of the bronchial tree in order: trachea-primary bronchi-secondary bronchi-tertiary bronchi-bronchioles-terminal. The trachea divides into the primary bronchi, which further divide into secondary bronchi, followed by tertiary bronchi, bronchioles, and finally terminal bronchioles. Choice A is incorrect because it lists "primary bronchi_trachea" which is out of order and "tertiary_bronchioles" instead of "tertiary bronchi." Choice C is incorrect because it combines the incorrect order of branches from both A and B. Choice D, "itis," is not a valid term related to the branches of the bronchial tree.
2,3 DPG causes shifting of Oxygen dissociation curve in Adult Hb to Right because
- A. It increases Oxygen affinity for Hemoglobin
- B. It binds to Beta chain of Hb
- C. Its concentration is high in adults
- D. It lacks Hb binding sites
Correct Answer: B
Rationale: The correct answer is B because 2,3 DPG binds to the Beta chain of Hemoglobin, reducing its oxygen affinity, causing a right shift in the Oxygen dissociation curve. This change allows for easier oxygen unloading in tissues. Choice A is incorrect as 2,3 DPG decreases, not increases, oxygen affinity. Choice C is irrelevant as its concentration is not a factor in the shifting of the curve. Choice D is incorrect as 2,3 DPG does bind to Hemoglobin, specifically to the Beta chain.
For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?
- A. Restricting fluid intake to 1,000 ml per day.
- B. Enforcing absolute bed rest.
- C. Teaching the patient how to perform controlled coughing.
- D. Administering prescribed sedatives regularly and in large amounts.
Correct Answer: C
Rationale: The correct answer is C: Teaching the patient how to perform controlled coughing. This intervention helps to clear mucus and secretions from the airways, maintaining a patent airway. Controlled coughing also prevents airway obstruction and promotes effective breathing. Restricting fluid intake (A) can lead to dehydration and thickening of secretions, worsening airway clearance. Enforcing bed rest (B) can cause decreased lung expansion and retention of secretions. Administering sedatives (D) can depress respiratory drive and worsen respiratory function.
Delegation Decision: The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)?
- A. Assist the patient to get out of bed.
- B. Auscultate breath sounds every 4 hours.
- C. Plan patient activities to minimize exertion.
- D. Teach the patient pursed lip breathing technique.
Correct Answer: A
Rationale: Assisting the patient to get out of bed can be safely delegated to unlicensed assistive personnel (UAP) as it does not require specialized nursing knowledge or skills. It is a basic activity of daily living that can be delegated to support staff while allowing nurses to focus on more complex patient care tasks.