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An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
- A. A low respiratory rate.
- B. Diminished breath sounds.
- C. The presence of a barrel chest.
- D. A sucking sound at the site of injury.
Correct Answer: B
Rationale: The correct answer is B: Diminished breath sounds. In the case of a pneumothorax, air leaks into the pleural space, causing the lung to collapse partially. This results in diminished or absent breath sounds on the affected side. A low respiratory rate (A) is a general sign of respiratory distress but not specific to pneumothorax. The presence of a barrel chest (C) is associated with conditions like chronic obstructive pulmonary disease (COPD) but not indicative of a pneumothorax. A sucking sound at the site of injury (D) is characteristic of an open pneumothorax, not necessarily present in all cases of pneumothorax.
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The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions shouldn't the nurse include in the teaching plan?
- A. Place contaminated tissues in sealable plastic bag.
- B. Take medications exactly as directed.
- C. Implement airborne precautions.
- D. Wash hands frequently.
Correct Answer: C
Rationale: The correct answer is C because TB is transmitted through droplet transmission, not airborne. The nurse should include hand hygiene (D) to prevent spread through contact, proper medication adherence (B) to treat TB effectively, and proper disposal of contaminated materials (A) to prevent spread through fomites. Implementing airborne precautions is not necessary for TB, as it does not remain suspended in the air for long periods.
A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess:
- A. Lung vibrations
- B. Vocal sounds
- C. Breath sounds
- D. Chest movements.
Correct Answer: D
Rationale: The correct answer is D: Chest movements. When checking respiratory status, observing chest movements, known as respiratory excursion, helps assess the depth and symmetry of breathing. This provides valuable information about lung expansion and function. Lung vibrations (A) are assessed by tactile fremitus, vocal sounds (B) by auscultating for voice sounds, and breath sounds (C) by listening for air movement in the lungs. However, these do not directly assess respiratory excursion.
A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met?
- A. Client reports pain is controlled satisfactorily with analgesic regime.
- B. Client does not have foul odor to the breath or beefy red mucus membranes.
- C. Client is able to swallow own secretions without drooling.
- D. Client's vital signs are within normal parameters.
Correct Answer: C
Rationale: Rationale:
The correct answer is C because the ability to swallow own secretions without drooling indicates that the client's airway is patent and functional post modUPPP, a priority goal for this procedure. This assessment finding ensures that the client can maintain a clear airway and prevent complications such as aspiration.
Incorrect choices:
A: Although pain control is important, it is not a priority assessment for this specific procedure.
B: Absence of foul odor or red mucus membranes is not directly related to the airway patency or swallowing ability.
D: While normal vital signs are reassuring, they do not directly indicate the success of the surgery in improving airway function.
Which of the following nursing interventions are involved when caring for a client with influenza?
- A. Maintain airborne transmission precautions
- B. Complete bed rest
- C. Oxygen administration
- D. Immediate recognition of respiratory distress
Correct Answer: D
Rationale: The correct answer is D. Immediate recognition of respiratory distress is vital in clients with influenza, especially those at risk of complications. A (airborne precautions) is unnecessary unless the client is immunocompromised. B (complete bed rest) is outdated practice. C (oxygen administration) is only needed if hypoxia is present.
The Alveolar epithelium is lined with
- A. Non-ciliated Squamous epithelium
- B. Ciliated Squamous epithelium
- C. Ciliated epithelium
- D. Ciliated Columnar epithelium
Correct Answer: A
Rationale: The correct answer is A: Non-ciliated Squamous epithelium. The alveolar epithelium in the lungs is composed of thin, flat cells called squamous epithelium. This type of epithelium allows for efficient gas exchange by providing a short diffusion distance. Ciliated epithelium (choice C) and ciliated columnar epithelium (choice D) are not found in the alveoli as they are more suited for moving mucus and debris in the respiratory tract. Ciliated squamous epithelium (choice B) is not a common epithelial type in the alveoli and is not as thin as non-ciliated squamous epithelium, making it less efficient for gas exchange.