Nokea
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?
- A. Immediately after a meal
- B. First thing in the morning
- C. At bedtime
- D. After a period of exercise
Correct Answer: B
Rationale: The correct answer is B: First thing in the morning. Sputum should be collected in the morning because it is usually more concentrated, making it easier to obtain a good sample. This is important for accurate analysis and identifying potential pathogens causing the patient's symptoms. Collecting sputum immediately after a meal may result in contamination with food particles. At bedtime, sputum may have accumulated overnight, but morning samples are still preferred due to concentration. Collecting sputum after a period of exercise may introduce respiratory secretions not reflective of the underlying condition.
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A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?
- A. Activity intolerance related to fatigue.
- B. Anxiety related to actual threat to health status.
- C. Risk for infection related to retained secretions.
- D. Impaired gas exchange related to airflow obstruction.
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to airflow obstruction. This is the most important nursing diagnosis for a patient with chronic obstructive pulmonary disease because impaired gas exchange directly impacts the patient's ability to breathe and obtain oxygen. Addressing this issue is crucial in managing the patient's condition and preventing further complications.
A: Activity intolerance related to fatigue may be a concern for the patient, but it is secondary to the primary issue of impaired gas exchange.
B: Anxiety related to actual threat to health status is important to address, but it is not the most critical nursing diagnosis for this patient.
C: Risk for infection related to retained secretions is a valid concern, but it is not as immediate and directly life-threatening as impaired gas exchange in a patient with chronic obstructive pulmonary disease.
The most important factor in determining the percent of oxygen saturation of hemoglobin
- A. The partial pressure of o2
- B. acidity
- C. the partial of co2
Correct Answer: A
Rationale: The correct answer is A: The partial pressure of O2. Oxygen saturation of hemoglobin is directly related to the partial pressure of oxygen in the blood. As the partial pressure of O2 increases, more oxygen binds to hemoglobin, leading to higher oxygen saturation. Acidity (choice B) and the partial pressure of CO2 (choice C) can influence the oxygen-hemoglobin dissociation curve, but they are not the primary factors determining oxygen saturation. Choice D is incomplete and not relevant to the question.
The collapse of lung is known as:
- A. pleurisy
- B. pleural effusion
- C. atelectasis
- D. pneumothorax
Correct Answer: C
Rationale: The correct answer is C: atelectasis. Atelectasis refers to the collapse of a lung or a part of a lung, leading to incomplete expansion of air sacs. This can be caused by various factors such as blockage of the airways or compression of the lung tissue. Pleurisy (A) is inflammation of the pleura, the lining around the lungs. Pleural effusion (B) is the accumulation of fluid in the pleural space. Pneumothorax (D) is the presence of air in the pleural space, leading to lung collapse. Atelectasis specifically describes the collapse of the lung itself, making it the correct choice.
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
- A. Administer an albuterol treatment.
- B. Notify the Rapid Response Team.
- C. Assess the client's peripheral pulses.
- D. Obtain blood and sputum cultures.
Correct Answer: B
Rationale: The correct answer is B: Notify the Rapid Response Team. Continuous cyanosis despite oxygen therapy following benzocaine administration may indicate methemoglobinemia, a serious adverse effect. Rapid Response Team should be alerted for immediate intervention and monitoring. Albuterol treatment (A) would not address methemoglobinemia. Assessing peripheral pulses (C) may not provide immediate assistance. Obtaining blood and sputum cultures (D) is not the priority in this situation.
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To help the client drink fluids
- C. To prevent respiratory obstruction
- D. To prevent excessive bleeding
Correct Answer: A
Rationale: The correct answer is A. An ice collar reduces swelling and pain by constricting blood vessels and numbing the area. B (helping the client drink fluids) is unrelated. C (preventing respiratory obstruction) is not the primary purpose of an ice collar. D (preventing excessive bleeding) is managed differently, usually with direct pressure or medication.