An 18-month-old child is brought to the emergency department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?
- A. Right upper lung
- B. Left upper lung
- C. Right lower lung
- D. Left lower lung
Correct Answer: A
Rationale: Aspiration of foreign objects is more likely in the right main stem bronchus and right upper lung. The right mainstem bronchus is slightly higher and more vertical than the left, which is why foreign articles are often aspirated here first.
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The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client?
- A. Watery sputum
- B. Loss of consciousness
- C. Respiratory distress
- D. Masses in pleural space
Correct Answer: C
Rationale: After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.
A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?
- A. Cilia
- B. Sinus cavity
- C. Tonsils
- D. Turbinates
Correct Answer: C
Rationale: Tonsils and adenoids do not contribute to respiration but protect against infection. Palatine tonsils are composed of lymphoid tissue. Cilia are fine hairs that move particles and liquid, preventing irritation and contamination of the airway. Sinuses are nasal cavity structures. Turbinates warm and add moisture to the inspired air.
What would the instructor tell the students purulent fluid indicates?
- A. Cancer
- B. Infection
- C. Inflammation
- D. Heart failure
Correct Answer: B
Rationale: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.
The nurse is providing health education on the body's ability to exchange oxygen and carbon dioxide through the alveolar capillary membrane. Which statement, provided by the nurse, is most correct when asked about diffusion during inspiration?
- A. During inspiration, the concentration of oxygen is equal in both the alveoli and the capillaries.
- B. During inspiration, oxygen diffuses from the arterial system through to the alveolar capillary membrane.
- C. During inspiration, carbon dioxide provides the basis for all diffusion gradients.
- D. During inspiration, oxygen is greater in the alveoli than in the capillaries.
Correct Answer: D
Rationale: During inspiration, oxygen-rich air from the environment enters the pulmonary system. During inspiration, the concentration of inspired oxygen is higher in the alveoli than in the capillaries, causing diffusion from the alveoli to the capillaries. Thus, the concentration of oxygen is not equal in the alveoli and capillaries. There is no diffusion from the arterial system after the oxygen diffuses from the alveoli to the capillaries. Carbon dioxide does not provide the basis for all diffusion gradients.
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
- A. Tickle the back of the throat to produce the gag reflex.
- B. Drink 8 oz of water to thin the secretions for expectoration.
- C. Use the secretions present in the oral cavity.
- D. Take deep breaths and cough forcefully.
Correct Answer: D
Rationale: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.
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