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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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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.
In an older client, the alveolar walls become thinner and contain fewer capillaries. What does this condition lead to?
- A. Loss of elasticity in the lungs
- B. Decreased gas exchange
- C. Increased stiffness in lungs
- D. Decreased numbers of alveoli
Correct Answer: B
Rationale: The correct answer is B (Decreased gas exchange). Thinning alveolar walls and reduced capillary density directly impair the diffusion of gases across the alveolar-capillary membrane, leading to decreased gas exchange. While A (loss of elasticity) might occur with aging, it is not the primary consequence here. C (increased stiffness) is incorrect because stiffness typically results from fibrosis or other conditions, not thinning walls. D (decreased numbers of alveoli) could happen but is unrelated to the specific scenario described.
Each of the following is true regarding the spleen, except:
- A. Spleen is located posterolateral to the stomach, and contacts the diaphragm and left kidney.
- B. Splenic veins, arteries, and lymphatic vessels communicate with the spleen at the hilum.
- C. The spleen is a primary lymphoid organ, serving to filter lymph fluid.
- D. Lymphocytes and dendritic cells are concentrated in the white pulp.
Correct Answer: C
Rationale: Rationale:
C is correct because the spleen is a secondary lymphoid organ, not a primary one. The spleen filters blood, not lymph fluid.
A is correct as the spleen is located in the described position.
B is correct as the splenic vessels do communicate with the spleen at the hilum.
D is correct as lymphocytes and dendritic cells are indeed concentrated in the white pulp.
Summary:
A, B, and D are correct statements about the spleen. C is incorrect because the spleen is a secondary lymphoid organ, not a primary one.
What is the proper sequence in the flow of air in humans?
- A. nasal cavities, larynx, pharynx, bronchi, trachea
- B. nasal cavities, pharynx, bronchi, larynx, trachea
- C. nasal cavities, pharynx, larynx, trachea, bronchi
- D. nasal cavities, larynx, pharynx, trachea, bronchi
Correct Answer: C
Rationale: The correct sequence is C: nasal cavities, pharynx, larynx, trachea, bronchi. Air enters through the nasal cavities, passes through the pharynx, then the larynx where the vocal cords are located, then enters the trachea, and finally branches into the bronchi leading to the lungs. This sequence follows the anatomical pathway of the respiratory system, ensuring proper filtration, warming, and humidification of the air. Choices A, B, and D have incorrect sequences that do not follow the anatomical order of the respiratory pathway, leading to an inaccurate flow of air in humans.
Which area represents the work to overcome airway resistance?
- A. ABCEA
- B. ABCFA
- C. AECFA
- D. ABCDOA
Correct Answer: C
Rationale: The correct answer is C: AECFA. This sequence represents the flow of air through the respiratory system. Airway resistance is primarily overcome by the contraction and relaxation of the smooth muscles in the airways. The correct sequence includes the airway segments that actively participate in regulating airway resistance - the trachea (A), bronchi (E), and bronchioles (C and F). The other choices do not include the correct segments that are involved in overcoming airway resistance.