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In assessing for major sources of infection in a COPD patient, the nurse focuses on:
- A. Stasis of respiratory secretions.
- B. Low body weight.
- C. Episodes of postural hypotension.
- D. Delayed antigen-antibody response.
Correct Answer: A
Rationale: The correct answer is A: Stasis of respiratory secretions. In COPD patients, stasis of respiratory secretions can lead to bacterial growth and increase the risk of infections like pneumonia. This is a common issue in COPD due to impaired mucociliary clearance. Choices B, C, and D are not directly related to sources of infection in COPD patients. Low body weight is more associated with malnutrition, postural hypotension with cardiovascular issues, and delayed antigen-antibody response with immune system deficiencies.
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As the nurse responsible for this client's care, you anticipate which physician's orders?
- A. Endotracheal intubation and mechanical ventilation
- B. Immediate application of CPAP to client's nose and mouth
- C. Intravenous furosemide (Lasix) 100 mg IV push stat
- D. Call a CODE for respiratory arrest.
Correct Answer: A
Rationale: The correct answer is A. Poor oxygenation despite non-rebreather mask suggests impending respiratory failure, necessitating intubation and mechanical ventilation. CPAP (B) and Lasix (C) may be considered but are secondary. Calling a CODE (D) is only if respiratory arrest occurs.
The lungs are covered by a two-layer membrane called the:
- A. pleura.
- B. diaphragm.
- C. respiratory membrane.
- D. intercostal muscles.
Correct Answer: A
Rationale: The correct answer is A: pleura. The pleura is a two-layered membrane that covers the lungs. The outer layer is called the parietal pleura, which lines the chest wall, and the inner layer is called the visceral pleura, which covers the lungs themselves. This double-layered structure helps to protect and cushion the lungs during breathing movements.
Summary of incorrect choices:
B: The diaphragm is a dome-shaped muscle located below the lungs that plays a role in breathing but does not cover the lungs.
C: The respiratory membrane refers to the interface where gas exchange occurs in the alveoli, not the covering of the lungs.
D: The intercostal muscles are located between the ribs and assist in breathing but do not cover the lungs.
The nurse is caring for a client who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
- A. O2 saturation is 88%
- B. Blood pressure is 155/90 mm Hg.
- C. Respiratory rate is 24 breaths/min when lying flat.
- D. Pain level is 5 (on 0 to 10 scale) with a deep breath.
Correct Answer: A
Rationale: The correct answer is A because a low O2 saturation level (88%) indicates potential respiratory compromise or hypoxemia post-thoracentesis, which requires immediate intervention to prevent hypoxia. The other choices are not as critical: B (BP slightly elevated but not urgent), C (RR slightly elevated but expected after procedure), and D (Pain at level 5 with deep breath is common post-thoracentesis and can be managed).
2,3 DPG is synthesized from 3- phosphoglyceraldehyde through
- A. Embden Meyerhof pathway
- B. Krebs Hensleit cycle
- C. Hexose monophosphate shunt
- D. Cori cycle
Correct Answer: A
Rationale: The correct answer is A: Embden Meyerhof pathway. In this pathway, 2,3 DPG is synthesized from 3-phosphoglyceraldehyde through a series of enzymatic reactions involving intermediates like 1,3-bisphosphoglycerate. This process occurs in the glycolysis pathway, specifically in the conversion of glyceraldehyde-3-phosphate to 1,3-bisphosphoglycerate by the enzyme phosphoglycerate kinase. The other choices, B: Krebs Hensleit cycle, C: Hexose monophosphate shunt, and D: Cori cycle, are not involved in the direct synthesis of 2,3 DPG from 3-phosphoglyceraldehyde. Krebs Hensleit cycle is the citric acid cycle, Hexose monophosphate shunt is the pentose phosphate pathway, and Cori cycle is the process of lactate recycling in the liver.
The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?
- A. Urine output is 500 mL during an 8-hour shift.
- B. Tremors are noted in the fingers when the patient extends the arms.
- C. The client reports a headache with pain at level 7
- D. The client cannot move the left arm when asked to do so.
Correct Answer: D
Rationale: The correct answer is D because the inability to move the left arm could indicate a neurological deficit or stroke, which is a critical finding that requires immediate medical attention in a hypertensive emergency. This could indicate a potential life-threatening condition that needs urgent intervention to prevent further complications.
A: Urine output is important but not as critical as potential neurological deficits in this scenario.
B: Tremors in the fingers are concerning but not as urgent as a potential neurological deficit.
C: Headache at level 7 is significant but not as critical as a neurological deficit that could indicate a stroke.