Nokea
Diaphragm is supplied with Phrenic nerve and is involved in
- A. Inspiration
- B. Parturition
- C. Micturition and Defecation
- D. All these
Correct Answer: D
Rationale: The correct answer is D: All these. The phrenic nerve innervates the diaphragm, which is responsible for inspiration (A). During parturition (B), the diaphragm plays a role in the pushing phase of labor. While the diaphragm is not directly involved in micturition and defecation (C), it indirectly affects these processes by helping to create intra-abdominal pressure. Therefore, the correct answer is D as the diaphragm is involved in inspiration, parturition, and indirectly affects micturition and defecation.
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A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:
- A. 1 L/min
- B. 2 L/min
- C. 6 L/min
- D. 10 L/min
Correct Answer: B
Rationale: The correct answer is B: 2 L/min. The rationale is that in emphysema, high oxygen flow rates can cause oxygen toxicity. The recommended maximum flow rate for patients with emphysema is typically 2 L/min to prevent oxygen toxicity. Choice A (1 L/min) may not provide sufficient oxygen, choice C (6 L/min) and choice D (10 L/min) are too high and can lead to oxygen toxicity in patients with emphysema. Therefore, choice B is the most appropriate and safe option for this client.
Which nursing activity is most important to include in the client's care?
- A. Perform postural drainage and chest physiotherapy every 4 hours.
- B. Discuss client's feelings about the need for a living will.
- C. Place in private room to decrease the risk of further infection.
- D. Plan activities to allow at least 8 hours of uninterrupted sleep.
Correct Answer: A
Rationale: The correct answer is A. Postural drainage and chest physiotherapy are critical for clearing secretions and improving lung function in cystic fibrosis. Discussing a living will (B), isolation (C), and sleep planning (D) are less urgent.
The nurse has instructed the client on how to obtain a sputum culture. Which of the statements indicates that the client understood the instruction from the nurse?
- A. I need to restrict my fluids 8 hours before obtaining the specimen.
- B. Mouth care should be avoided before collecting the sputum specimen.
- C. The best time to obtain the specimen is late at night.
- D. I just need to breathe deeply, followed by coughing up the sputum.
Correct Answer: D
Rationale: The correct answer is D because the client demonstrates understanding by acknowledging the need to breathe deeply and cough up the sputum to obtain a sputum culture. This action helps bring up the lower respiratory tract secretions for an accurate culture. Choice A is incorrect because increasing fluids actually helps in sputum production. Choice B is incorrect as mouth care should be done before to prevent contamination. Choice C is incorrect as early morning is the best time due to the accumulation of secretions overnight.
A client who is human immunodeficiency virus-positive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as:
- A. Positive
- B. Negative
- C. Inconclusive
- D. Indicating the need for repeat testing.
Correct Answer: A
Rationale: The correct answer is A: Positive. In individuals with HIV, a positive Mantoux test is considered when the induration is 5 mm or greater. A 7-mm area of induration indicates a positive result, suggesting an immune response to the tuberculin antigen, potentially due to latent tuberculosis infection. The other choices are incorrect because a 7-mm induration in an HIV-positive client is not considered negative, inconclusive, or indicative of the need for repeat testing based on current guidelines.
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?
- A. Obtain a sputum sample.
- B. Perform a swallowing assessment.
- C. Inspect the patient's tongue and mouth.
- D. Assess the patient's nutritional status.
Correct Answer: B
Rationale: The correct answer is B: Perform a swallowing assessment. This is the best follow-up because coughing after eating or drinking can be a sign of dysphagia, a swallowing disorder. By performing a swallowing assessment, the nurse can identify any issues with the patient's ability to swallow safely, which can lead to aspiration and respiratory complications. Obtaining a sputum sample (A) may not provide relevant information in this context. Inspecting the patient's tongue and mouth (C) may not directly address the coughing after eating. Assessing the patient's nutritional status (D) is important but may not address the immediate issue of coughing after eating or drinking.