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A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. What is an expected outcome for this patient?
- A. SpO is 90%
- B. Lungs clear to auscultation
- C. Patient tolerates walking in hallway
- D. Patient takes three or four shallow breaths before coughing to minimize pain
Correct Answer: D
Rationale: The expected outcome for a patient with ineffective airway clearance would be for the patient to take three or four shallow breaths before coughing to minimize pain, which indicates effective clearing of airway secretions. The other options do not directly relate to the nursing diagnosis provided.
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What is heart failure?
- A. A sudden stoppage of the heart
- B. Inability of the heart to pump blood effectively
- C. Accumulation of excess cholesterol in the arteries
- D. Irregular heartbeat
Correct Answer: B
Rationale: The correct answer is B: Inability of the heart to pump blood effectively. Heart failure occurs when the heart is unable to pump blood efficiently to meet the body's needs. This can lead to symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation:
1. Heart failure is a chronic condition that develops over time due to various factors such as high blood pressure, heart attacks, or heart muscle damage.
2. The inability of the heart to pump blood effectively results in reduced blood flow to the body's organs and tissues.
3. This can lead to a buildup of fluid in the lungs and other parts of the body, causing symptoms like shortness of breath and swelling.
4. A sudden stoppage of the heart (Choice A) would result in cardiac arrest, not heart failure.
5. Accumulation of excess cholesterol in the arteries (Choice C) refers to atherosclerosis, not heart failure.
6. An irregular heartbeat (Choice D) may be a symptom
For a male client with an endotracheal (ET) tube, which nursing action is most essential?
- A. Auscultating the lungs for bilateral breath sounds.
- B. Turning the client from side to side every 2 hours.
- C. Monitoring serial blood gas values every 4 hours.
- D. Providing frequent oral hygiene.
Correct Answer: A
Rationale: The correct answer is A: Auscultating the lungs for bilateral breath sounds. This is the most essential nursing action for a male client with an endotracheal tube because it ensures proper placement of the tube and adequate ventilation. By auscultating the lungs, the nurse can assess for any potential complications such as tube displacement, pneumothorax, or mucus plugging. This action helps in early detection of respiratory issues and prompt intervention if needed.
Summary:
- Choice B (Turning the client from side to side every 2 hours) is important for preventing pressure ulcers but not as critical as assessing breath sounds.
- Choice C (Monitoring serial blood gas values every 4 hours) is important for evaluating respiratory status but does not provide immediate information on tube placement.
- Choice D (Providing frequent oral hygiene) is important for preventing infections but does not directly assess the client's respiratory status with an ET tube.
2,3 DPG is synthesized from 3- phosphoglyceraldehyde through
- A. Embden Meyerhof pathway
- B. Krebs Hensleit cycle
- C. Hexose monophosphate shunt
- D. Cori cycle
Correct Answer: A
Rationale: The correct answer is A: Embden Meyerhof pathway. In this pathway, 2,3 DPG is synthesized from 3-phosphoglyceraldehyde through a series of enzymatic reactions involving intermediates like 1,3-bisphosphoglycerate. This process occurs in the glycolysis pathway, specifically in the conversion of glyceraldehyde-3-phosphate to 1,3-bisphosphoglycerate by the enzyme phosphoglycerate kinase. The other choices, B: Krebs Hensleit cycle, C: Hexose monophosphate shunt, and D: Cori cycle, are not involved in the direct synthesis of 2,3 DPG from 3-phosphoglyceraldehyde. Krebs Hensleit cycle is the citric acid cycle, Hexose monophosphate shunt is the pentose phosphate pathway, and Cori cycle is the process of lactate recycling in the liver.
Which statement is NOT true?
- A. Carbon dioxide is more soluble in fluid than in oxygen.
- B. Carbon dioxide diffuses more rapidly across the respiratory surface than does oxygen.
- C. The major muscle involved in breathing is the diaphragm.
- D. Oxygen is carried primarily by blood plasma
Correct Answer: D
Rationale: The correct answer is D. Oxygen is primarily carried by hemoglobin in red blood cells, not blood plasma. Hemoglobin binds to oxygen, forming oxyhemoglobin for transport. Option A is false because oxygen is more soluble in fluid than carbon dioxide. Option B is incorrect as oxygen diffuses slower than carbon dioxide due to its larger molecular size. Option C is true as the diaphragm is the main muscle involved in breathing, contracting to expand the lungs during inhalation.
The impulse for voluntary muscles for forced breathing starts in
- A. Medulla ( pons )
- B. Vagus nerve
- C. Cerebral hemispheres
- D. Spinal cord
Correct Answer: A
Rationale: The correct answer is A: Medulla (pons). The medulla, located in the brainstem, controls involuntary functions like breathing. Specifically, the medulla contains the respiratory center, which regulates breathing rhythm and depth. During forced breathing, the medulla sends impulses to the voluntary muscles involved in breathing, such as the diaphragm and intercostal muscles. The pons, which is closely connected to the medulla, assists in regulating breathing patterns. The vagus nerve (B) is responsible for parasympathetic functions, not voluntary breathing. The cerebral hemispheres (C) are primarily involved in higher brain functions, not breathing regulation. The spinal cord (D) plays a role in transmitting signals between the brain and muscles but does not initiate voluntary breathing impulses.