Nokea
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on which finding?
- A. SpO of 86%
- B. Crackles in both lower lobes
- C. Temperature of 101.4ºF (38.6ºC)
- D. Production of greenish purulent sputum
Correct Answer: A
Rationale: Impaired gas exchange is indicated by a low SpO2 level, in this case 86%, which suggests inadequate oxygenation. Crackles, temperature, and sputum production are important assessments but do not directly indicate impaired gas exchange.
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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.
The organ of the respiratory system that closes when food is being swallowed is the:
- A. nose
- B. pharynx
- C. larynx
- D. trachea
Correct Answer: C
Rationale: The correct answer is C: larynx. The larynx houses the vocal cords and serves as a passageway for air between the pharynx and trachea. During swallowing, the larynx closes to prevent food and liquids from entering the airway, directing them towards the esophagus instead. The nose (A) is not directly involved in swallowing. The pharynx (B) is a shared pathway for both air and food, but it does not actively close during swallowing. The trachea (D) is responsible for transporting air to and from the lungs and does not play a role in swallowing.
How does the pressure 'P4' at label '4' compare to the pressure 'P5' at label '5'?
- A. P4 is higher than P5 during inhalation and then lower during exhalation
- B. P4 is always higher than P5
- C. P4 is always lower than P5
- D. P4 always equals P5
Correct Answer: C
Rationale: The correct answer is C because pressure decreases as air moves from a region of higher pressure to lower pressure. At label '4', the air pressure is higher due to inhalation, and at label '5', the pressure is lower as air exits during exhalation. Therefore, P4 is always lower than P5. Choices A and B are incorrect because pressure dynamics change during inhalation and exhalation. Choice D is incorrect as pressure imbalances exist during breathing.
Which of the following would be the most appropriate nursing intervention when caring for a client with a fractured rib?
- A. Apply immobilization device after examination by physician
- B. Discourage taking deep breaths if breathing is painful
- C. Advice against using analgesics and regional nerve blocks
- D. Encourage increased fluid intake if pulmonary contusion exists
Correct Answer: A
Rationale: The correct answer is A. Applying an immobilization device after physician evaluation helps stabilize the rib and reduce pain. B (discouraging deep breaths) is harmful as it can lead to atelectasis. C (advising against analgesics) is incorrect because pain management is essential. D (increasing fluid intake) is secondary and depends on the presence of pulmonary complications.
Tachypnoea means
- A. Rapid shallow breathing
- B. Rapid deep breathing
- C. Slow and shallow breathing
- D. Slow and deep breathing
Correct Answer: A
Rationale: The correct answer is A: Rapid shallow breathing. Tachypnoea refers to an increased respiratory rate, which can lead to shallow breathing. Rapid breathing helps to compensate for inadequate oxygen levels. Choice B is incorrect because tachypnoea is not typically associated with deep breathing. Choices C and D are incorrect as they describe slow breathing patterns, which are opposite to tachypnoea.