Nokea
An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?
- A. Assess the client's lung sounds.
- B. Assign a different AP to the client.
- C. Report the AP to the manager.
- D. Request thicker liquids for meals.
Correct Answer: A
Rationale: Correct Answer: A - Assess the client's lung sounds.
Rationale:
1. Assessing lung sounds helps determine if the client is experiencing respiratory distress.
2. Coughing during a meal with a tracheostomy can indicate aspiration or airway obstruction.
3. Prompt assessment can prevent potential complications and guide further interventions.
Summary:
- B: Assigning a different AP does not address the client's immediate respiratory status.
- C: Reporting the AP to the manager is not necessary before assessing the client's condition.
- D: Requesting thicker liquids does not address the underlying issue of potential aspiration or airway obstruction.
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Sputum specimens are examined to detect which of the following?
- A. Foreign bodies
- B. Cancer cells
- C. Pulmonary emboli
- D. Inflammation
Correct Answer: B
Rationale: The correct answer is B. Sputum specimens are often examined for cancer cells in cases of suspected lung cancer. While foreign bodies (A) can sometimes be identified, they are less common in routine sputum analysis. Pulmonary emboli (C) cannot be detected via sputum examination; imaging studies are required. Inflammation (D) may be inferred from white blood cell counts, but detecting cancer cells is more specific and clinically significant.
The partial pressure of carbon dioxide in venous blood is approximately
- A. 40 mm Hg
- B. 45 mm Hg
- C. 50 mm Hg
- D. 70 mm Hg
Correct Answer: B
Rationale: The correct answer is B (45 mm Hg) because the partial pressure of carbon dioxide in venous blood is typically around 40-45 mm Hg. This value represents the amount of CO2 dissolved in the blood plasma. Option A (40 mm Hg) is slightly on the lower side and may not fully reflect the average value. Option C (50 mm Hg) is higher than the usual range for venous blood CO2 levels. Option D (70 mm Hg) is significantly higher than the normal range and is more characteristic of arterial blood CO2 levels. Therefore, option B is the most accurate representation of the partial pressure of CO2 in venous blood.
The last mammalian structure that air moves through before the alveoli is the
- A. larynx.
- B. glottis.
- C. bronchioles.
- D. trachea.
Correct Answer: C
Rationale: The correct answer is C: bronchioles. After air passes through the trachea, it enters the bronchi, which further divide into bronchioles. The bronchioles are the last structures where air passes before reaching the alveoli for gas exchange. The larynx is involved in sound production and the glottis is the opening between the vocal cords in the larynx. While the trachea is the initial passage for air into the respiratory system, the bronchioles are the final branching structures where air reaches the alveoli, making them the correct answer.
A male client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects Legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating Legionnaires' disease?
- A. erythromycin (Erythrocin)
- B. rifampin (Rifadin)
- C. amantadine (Symmetrel)
- D. amphotericin B (Fungizone)
Correct Answer: A
Rationale: The correct answer is A: erythromycin (Erythrocin). Legionnaires' disease is caused by the bacterium Legionella pneumophila, and erythromycin is the drug of choice for treating this infection. Erythromycin is a macrolide antibiotic that effectively targets Legionella bacteria by inhibiting their protein synthesis. It is bacteriostatic at low concentrations and bactericidal at higher concentrations. Rifampin (B) is not the preferred choice for Legionnaires' disease. Amantadine (C) is used for treating influenza A virus, not Legionella bacteria. Amphotericin B (D) is an antifungal agent and is not effective against Legionella pneumophila. Utilizing erythromycin as the treatment of choice ensures successful eradication of the Legionella bacteria and helps the client recover from the infection.
The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse NOT include?
- A. Insurance will cover the cost if you wear it at least 4 hours a day.
- B. Once the delivery mask is adjusted, do not loosen the straps.
- C. The CPAP provides pressure that holds your upper airways open.
- D. You need to clean the mask at least once a week to prevent infection.
Correct Answer: A
Rationale: The correct answer is A because insurance coverage for CPAP machines is generally not based on the number of hours it is worn per day but rather on medical necessity. The nurse would not include this information as it could lead to misunderstanding and incorrect assumptions. Choice B is incorrect because adjusting the mask may be necessary for comfort. Choice C is correct as CPAP does provide pressure to keep airways open. Choice D is also correct as cleaning the mask regularly is essential to prevent infections.