Nokea
diaphragm relaxes and decrease thoracic space in which phase of respiration.
- A. inspiration
- B. expiration
- C. Pause
- D. both a and b
Correct Answer: B
Rationale: During expiration, the diaphragm relaxes, causing it to move upwards, which decreases the thoracic space. This leads to the expulsion of air from the lungs. In contrast, during inspiration, the diaphragm contracts and moves downwards, increasing the thoracic space to allow air to enter the lungs. Option C, Pause, does not involve any specific respiratory phase. Option D, both a and b, is incorrect because during inspiration, the diaphragm contracts and increases thoracic space. Therefore, the correct answer is B, expiration, as this phase specifically involves the relaxation of the diaphragm and the decrease in thoracic space.
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A client with pneumonia has a fever of 101.4° F (38.6° C) a nonproductive cough and an O2 saturation of 88%. The client is weak and needs assistance to get out of bed. Which client problem should the nurse assign as the priority?
- A. Fatigue
- B. Hyperthermia
- C. Impaired mobility
- D. Impaired gas exchange
Correct Answer: D
Rationale: The correct answer is D, Impaired gas exchange. This is the priority because the client's O2 saturation of 88% indicates poor oxygenation, which can lead to serious complications like hypoxemia. The fever and nonproductive cough are symptoms of pneumonia contributing to impaired gas exchange. Addressing this issue is crucial to prevent respiratory distress.
A: Fatigue - While important, fatigue is a secondary concern compared to impaired gas exchange, which directly affects oxygenation and can be life-threatening.
B: Hyperthermia - The client's fever is likely related to the pneumonia but managing impaired gas exchange takes precedence as it directly impacts oxygen delivery to tissues.
C: Impaired mobility - While assisting the client out of bed is necessary, the priority is to address the underlying problem of impaired gas exchange to prevent respiratory compromise.
The partial pressure of oxygen in arterial blood is approximately
- A. 40 mm Hg
- B. 100 mm Hg
- C. 50 mm Hg
- D. 70 mm Hg
Correct Answer: B
Rationale: The correct answer is B: 100 mm Hg. In arterial blood, the partial pressure of oxygen is typically around 100 mm Hg due to the oxygen-rich environment in the lungs. This value represents the pressure exerted by oxygen molecules in the blood. Choices A, C, and D are incorrect because they do not align with the normal range of oxygen partial pressure in arterial blood, which is around 100 mm Hg. Option A is too low, option C is slightly below the normal range, and option D is slightly above the normal range. Therefore, B is the most accurate representation of the typical partial pressure of oxygen in arterial blood.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
- A. Their location over a specific area of the lung
- B. The volume of the sounds
- C. Whether they are heard on inspiration or expiration
- D. Whether or not they are continuous breath sounds
Correct Answer: A
Rationale: The correct answer is A because vesicular, bronchovesicular, and bronchial breath sounds are distinguished based on their location over specific areas of the lung. Vesicular sounds are soft and low-pitched and are heard over most of the lung fields, bronchovesicular sounds are intermediate in pitch and are heard over the major bronchi, and bronchial sounds are loud and high-pitched and are heard over the trachea and larynx. Choices B, C, and D are incorrect as the distinction between these breath sounds is not based on volume, inspiration or expiration, or continuity of the sounds.
The organ of the respiratory system that is kept open by rings of cartilage is the:
- A. nose
- B. pharynx
- C. larynx
- D. trachea
Correct Answer: D
Rationale: The correct answer is D: trachea. The trachea is kept open by rings of cartilage to prevent collapse during inhalation. The nose (A) is primarily involved in filtering, warming, and moistening air. The pharynx (B) is a common pathway for both air and food. The larynx (C) houses the vocal cords and aids in sound production but does not have cartilage rings to keep it open.
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.