Nokea
A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?
- A. Acid-base balance
- B. Perfusion
- C. Diffusion
- D. Ventilation
Correct Answer: B
Rationale: The correct answer is B: Perfusion. Pulmonary hypertension affects blood flow through the lungs, leading to decreased perfusion. This results in inadequate oxygenation of the blood. Acid-base balance (A) is maintained by the kidneys and lungs, not directly impacted by pulmonary hypertension. Diffusion (C) refers to gas exchange in the alveoli, which is affected by perfusion but not the primary disturbance in pulmonary hypertension. Ventilation (D) is the process of moving air in and out of the lungs, which is not primarily affected by pulmonary hypertension; it is more related to conditions like COPD.
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An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?
- A. Assess the client's lung sounds.
- B. Assign a different AP to the client.
- C. Report the AP to the manager.
- D. Request thicker liquids for meals.
Correct Answer: A
Rationale: Correct Answer: A - Assess the client's lung sounds.
Rationale:
1. Assessing lung sounds helps determine if the client is experiencing respiratory distress.
2. Coughing during a meal with a tracheostomy can indicate aspiration or airway obstruction.
3. Prompt assessment can prevent potential complications and guide further interventions.
Summary:
- B: Assigning a different AP does not address the client's immediate respiratory status.
- C: Reporting the AP to the manager is not necessary before assessing the client's condition.
- D: Requesting thicker liquids does not address the underlying issue of potential aspiration or airway obstruction.
The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse NOT include?
- A. Insurance will cover the cost if you wear it at least 4 hours a day.
- B. Once the delivery mask is adjusted, do not loosen the straps.
- C. The CPAP provides pressure that holds your upper airways open.
- D. You need to clean the mask at least once a week to prevent infection.
Correct Answer: A
Rationale: The correct answer is A because insurance coverage for CPAP machines is generally not based on the number of hours it is worn per day but rather on medical necessity. The nurse would not include this information as it could lead to misunderstanding and incorrect assumptions. Choice B is incorrect because adjusting the mask may be necessary for comfort. Choice C is correct as CPAP does provide pressure to keep airways open. Choice D is also correct as cleaning the mask regularly is essential to prevent infections.
Which vital sign should she immediately report to you—the RN?
- A. Heart rate 98 per minute
- B. Respiratory rate 24 per minute
- C. Blood pressure 168/90
- D. Tympanic temperature 101.4°F
Correct Answer: D
Rationale: The correct answer is D. A temperature of 101.4°F indicates possible infection or complication and requires immediate attention. Heart rate (A), respiratory rate (B), and blood pressure (C) are within acceptable ranges post-suctioning.
The nurse is performing an occupational history as part of the respiratory assessment. Which occupation(s) place the patient isn't at increased risk for an occupational lung disorder?
- A. A firefighter
- B. A cotton gin worker
- C. A construction contractor
- D. A bartender
Correct Answer: D
Rationale: The correct answer is D: A bartender. Bartenders are not typically exposed to occupational lung hazards like smoke, dust, or chemicals. Firefighters (A), cotton gin workers (B), and construction contractors (C) are all at increased risk due to exposure to smoke, cotton dust, and construction materials, respectively. As a result, the bartender is the least likely to develop an occupational lung disorder compared to the other professions listed.
How much does the inspired O2 concentration have to be raised to abolish the hypoxaemia?
- A. 5%
- B. 7%
- C. 10%
- D. 15%
Correct Answer: B
Rationale: The correct answer is B (7%). To abolish hypoxemia, inspired O2 concentration needs to be increased sufficiently to raise arterial oxygen levels. A 7% increase is generally effective in achieving this without causing oxygen toxicity. Choices A, C, and D are incorrect because a 5% increase may not be enough to abolish hypoxemia, a 10% increase can lead to oxygen toxicity, and a 15% increase is excessive and unnecessary for treating hypoxemia. Therefore, option B is the most appropriate and balanced choice for addressing hypoxemia effectively.