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A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?
- A. Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray.
- B. Turn the patient to enable assessment of all the patient's lung fields.
- C. Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall.
- D. Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.
Correct Answer: B
Rationale: The correct answer is B because turning the patient to enable assessment of all the lung fields is the best approach to assess lung sounds comprehensively. By turning the patient, the nurse can listen to breath sounds on both the anterior and posterior chest walls, ensuring a thorough assessment. Option A is incorrect as it assumes the need for a chest x-ray without first performing a physical assessment. Option C is incorrect as it limits assessment to only the anterior chest wall, potentially missing abnormalities in the posterior lung fields. Option D is incorrect as obtaining a pulse oximetry reading and repositioning the patient should not replace the need for a physical assessment of lung sounds.
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Which statement is false about anatomical dead space?
- A. Anatomical dead space varies with age
- B. Can be estimated by the Fowlers method
- C. Significantly large in shallow breathing
- D. Measured by plotting N2 concentration against expired volume as in Bohr’s method
Correct Answer: D
Rationale: The correct answer is D because Bohr's method measures physiological dead space, not anatomical dead space. Anatomical dead space is constant and not affected by N2 concentration. A: Anatomical dead space does vary with age due to changes in lung dimensions. B: Fowlers method estimates anatomical dead space by measuring tidal volume and respiratory rate. C: Anatomical dead space is not significantly large in shallow breathing as it mainly involves the conducting airways, not the alveoli.
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is appropriate because equal AP and lateral chest diameters could indicate barrel chest, which is often associated with chronic obstructive pulmonary disease (COPD) or other chronic breathing problems. Asking about chronic breathing problems can help the nurse further assess the client's respiratory health.
Incorrect answers:
A: Are you taking any medications or herbal supplements? This question is not directly related to the observed chest diameter findings.
C: How often do you perform aerobic exercise? This question is not relevant to the physical assessment findings and does not address the potential respiratory issue.
D: What is your occupation and what are your hobbies? This question does not directly address the equal AP and lateral chest diameters and does not help in assessing the respiratory status of the client.
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?
- A. Document the findings.
- B. Administer oxygen therapy.
- C. Position the client in high-Fowlers position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct answer is A: Document the findings. The nurse should first document the assessment findings to establish a baseline and communicate the abnormal sound to the healthcare team for further evaluation. This is crucial for accurate diagnosis and treatment planning. Administering oxygen therapy (B) may be needed depending on the client's oxygen saturation but is not the priority in this situation. Positioning the client in high-Fowlers position (C) may help with breathing but does not address the underlying cause of the abnormal sound. Administering albuterol (D) may be indicated for bronchospasm but should not be done without understanding the cause of the harsh hollow sound first.
A male adult client is suspected of having a pulmonary embolism. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?
- A. Dyspnea
- B. Bradypnea
- C. Bradycardia
- D. Decreased respirations
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Pulmonary embolism causes a blockage in the pulmonary arteries, leading to decreased oxygenation and subsequent shortness of breath. To assess for pulmonary embolism, a nurse would look for symptoms such as sudden onset dyspnea. Bradypnea (B) refers to abnormally slow breathing rate, which is not typically seen in pulmonary embolism. Bradycardia (C) is a slow heart rate, which may occur in some cases but is not a common clinical manifestation of pulmonary embolism. Decreased respirations (D) is too vague and does not specifically indicate the difficulty in breathing associated with pulmonary embolism.
Which type of acid-base imbalance can result from the inhibition of carbonic anhydrase?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: Carbonic anhydrase catalyzes the conversion of carbon dioxide and water into carbonic acid, which then dissociates into bicarbonate and hydrogen ions. Inhibition of carbonic anhydrase leads to decreased bicarbonate levels, causing metabolic alkalosis. Without adequate bicarbonate, the body accumulates excess base, resulting in alkalosis. Metabolic acidosis (A) is incorrect because inhibition of carbonic anhydrase would lead to excess base, not acid. Respiratory acidosis (B) and respiratory alkalosis (D) are incorrect as they are caused by respiratory, not metabolic, disturbances.