Nokea
A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. Which action should be the nurse's initial intervention?
- A. Report signs to the charge nurse.
- B. Elevate head of bed and administer oxygen.
- C. Prevent patient from excessive coughing.
- D. Increase IV flow rate.
Correct Answer: B
Rationale: When a pulmonary embolus is suspected, the head of the bed should be elevated to facilitate respiration and oxygen is administered. The charge nurse and the health care provider should be notified, but only after the patient is positioned and oxygenated.
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Which event happens when there is a decrease in the oxygen level in the blood?
- A. Pituitary stimulates the respiratory system to increase respiratory rate.
- B. The alveoli diffuse more oxygen into the blood.
- C. Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates.
- D. The parietal pleura increases the negative pressure.
Correct Answer: C
Rationale: The chemoreceptors in the carotid bodies and the aortic bodies send a message to the respiratory centers to modify respirations.
An 83-year-old patient is admitted with a temperature of 102°F (38.8°C), chest pain, and fatigue. Which term describes the infected fluid that the health care provider removes from the pleural cavity?
- A. Emboli
- B. Emphysema
- C. Sputum
- D. Empyema
Correct Answer: D
Rationale: If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema.
Which action is the purpose of the cilia?
- A. Warm and moisturize inhaled air.
- B. Sweep debris toward nasal cavity.
- C. Stimulate cough reflex.
- D. Produce mucus.
Correct Answer: B
Rationale: The cilia are fine hairlike processes on the outer surfaces of small cells that produce a motion that sweeps the debris toward the nasal cavity. Large particles that are swept away stimulate the cough reflex, but not the cilia themselves.
A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this?
- A. Only 82% of the red blood cells are able to use oxygen.
- B. There is only 82% of oxygen bound to the hemoglobin compared with the amount available.
- C. Eighteen percent of oxygen is not dissolved in the blood.
- D. The muscular respiratory effort is only 18% effective.
Correct Answer: B
Rationale: An SaO2 of 82% indicates that only 82% of the available oxygen is bound to the hemoglobin.
Which patient assessment indicates the most severe respiratory distress?
- A. Nasal flaring, symmetrical chest wall expansion, SaO2 88%
- B. Abdominal breathing, SaO2 97%
- C. Substernal retraction, SaO2 84%
- D. Substernal retraction, SaO2 90%
Correct Answer: C
Rationale: Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress.