Nokea
Expiration involves
- A. Relaxation of diaphragm and intercostals muscles
- B. Contraction of diaphragm and intercostals muscles
- C. Contraction of diaphragm muscles
- D. Contraction of inter costal muscles
Correct Answer: A
Rationale: The correct answer is A because expiration involves the relaxation of the diaphragm and intercostal muscles. During expiration, the diaphragm moves up and the intercostal muscles relax, causing the thoracic cavity to decrease in volume. This increase in pressure forces air out of the lungs. Choice B is incorrect as it describes the process of inspiration, not expiration. Choice C is incorrect because expiration involves both the diaphragm and intercostal muscles, not just the diaphragm muscles. Choice D is incorrect as the intercostal muscles also relax during expiration, rather than contracting.
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Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 78-yr-old patient with newly diagnosed hypertension?
- A. 98/56 mm Hg
- B. 118/76 mm Hg
- C. 128/92 mm Hg
- D. 142/78 mm Hg
Correct Answer: B
Rationale: The correct answer is B (118/76 mm Hg) because it falls within the recommended range for a 78-year-old patient with hypertension. The systolic BP should ideally be below 140 mm Hg and the diastolic BP below 90 mm Hg for this age group. Option A is too low for systolic BP, indicating hypotension. Option C has elevated diastolic BP, suggesting uncontrolled hypertension. Option D has high systolic BP, indicating a need for therapy adjustment. Thus, only option B aligns with the guidelines, making it the correct choice.
A hospital nurse is participating in a drill during which many "clients" with inhalation anthrax are being admitted. The nurse would anticipate administering the following EXCEPT?
- A. Vancomycin
- B. Ciprofloxacin
- C. Doxycycline
- D. Ethambutol
Correct Answer: D
Rationale: The correct answer is D: Ethambutol. Ethambutol is not used in the treatment of inhalation anthrax. The treatment of choice for inhalation anthrax is a combination of antibiotics such as ciprofloxacin, doxycycline, and sometimes vancomycin. Ethambutol is primarily used in the treatment of tuberculosis, not anthrax. It is important for the nurse to be knowledgeable about the appropriate medications for specific conditions to provide effective care.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:
- A. Exhale slowly
- B. Stay very still
- C. Inhale and exhale quickly
- D. Perform the Valsalva maneuver
Correct Answer: D
Rationale: The correct answer is D: Perform the Valsalva maneuver. The Valsalva maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during chest tube removal, reducing the risk of a pneumothorax. Exhaling slowly (A) or inhaling and exhaling quickly (C) can increase the risk of air entering the pleural space. Staying very still (B) is important to minimize movement during the procedure, but performing the Valsalva maneuver is crucial to prevent complications.
Which action should the nurse take first when a client develops epistaxis?
- A. Pack the affected nostril tightly with an epistaxis balloon.
- B. Apply squeezing pressure to the nostrils for 10 minutes.
- C. Obtain silver nitrate that may be needed for cauterization.
- D. Instill a vasoconstrictor medication into the affected nostril.
Correct Answer: B
Rationale: The correct action is to apply squeezing pressure to the nostrils for 10 minutes. This helps control the bleeding by promoting clot formation. It is the initial intervention to stop the bleeding before considering other options. Packing the nostril with a balloon (Choice A) may worsen the bleeding. Obtaining silver nitrate (Choice C) for cauterization is not the first-line approach. Instilling vasoconstrictor medication (Choice D) should be considered after applying pressure if bleeding persists.
Food and drink are prevented from entering the respiratory passageways during swallowing by means of the
- A. glottis.
- B. pharynx.
- C. epiglottis.
- D. larynx.
Correct Answer: C
Rationale: The correct answer is C: epiglottis. During swallowing, the epiglottis covers the opening of the larynx to prevent food and drink from entering the respiratory passageways. It acts as a lid that directs food and liquids to the esophagus instead of the trachea. The glottis (choice A) is the space between the vocal cords, the pharynx (choice B) is the passageway for food and air, and the larynx (choice D) contains the vocal cords. The epiglottis specifically functions to protect the airway during swallowing.