Nokea
Rectal respiration is seen in
- A. Cockroach
- B. Spider
- C. Niads of Dragon fly
- D. Water flea
Correct Answer: C
Rationale: Rectal respiration in insects involves the exchange of gases through the anus. The correct answer is C, Niads of Dragonfly, as they have specialized structures called rectal gills for respiration. Cockroach (A), Spider (B), and Water flea (D) do not possess rectal gills or exhibit rectal respiration. Cockroaches have spiracles for respiration, spiders have book lungs or tracheal systems, and water fleas have gills located elsewhere on their bodies. Thus, only Niads of Dragonfly demonstrate rectal respiration, making it the correct choice.
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A client who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry hacking cough. Which action should the nurse take first?
- A. Auscultate the abdomen
- B. Check the capillary refill
- C. Auscultate the breath sounds
- D. Ask about the patient's allergies
Correct Answer: C
Rationale: The correct action for the nurse to take first is to auscultate the breath sounds (Choice C) because the client is presenting with severe dyspnea and a dry hacking cough, which are indicative of respiratory distress in a patient with chronic heart failure. Auscultating the breath sounds will help the nurse assess the presence of crackles, wheezing, or decreased air entry, providing crucial information about the client's respiratory status and guiding immediate interventions. Checking the capillary refill (Choice B) is important but not the priority in this situation. Auscultating the abdomen (Choice A) is not relevant to the presenting symptoms. Asking about the patient's allergies (Choice D) is important but can be addressed after addressing the immediate respiratory distress.
After the nurse teaches the client with stage 1 hypertension about diet modifications.Which diet choice indicates that the teaching has been most effective?
- A. The client avoids eating salted nuts.
- B. The client restricts intake of chicken and fish.
- C. The client drinks a sugary beverage with each meal.
- D. The client has two cups of coffee in the morning.
Correct Answer: A
Rationale: The correct answer is A because avoiding salted nuts helps reduce sodium intake, which is crucial for managing hypertension. Salt can increase blood pressure. Choice B is incorrect as chicken and fish can be part of a healthy diet. Choice C is incorrect as sugary beverages can worsen hypertension. Choice D is incorrect as excessive caffeine intake can raise blood pressure. In summary, choice A is the most effective as it directly addresses reducing sodium intake, which is essential for managing hypertension.
A patient on the medical unit has told the nurse that he is experiencing significant
dyspnea, despite that he has not recently performed any physical activity. What
assessment question should the nurse ask the patient while preparing to perform a
physical assessment?
- A. On a scale from 1 to 10, how bad would rate your shortness of breath?
- B. When was the last time you ate or drank anything?
- C. Are you feeling any nausea along with your shortness of breath?
- D. Do you think that some medication might help you catch your breath?
Correct Answer: A
Rationale: Rationale for Correct Answer (A):
1. Assessing the severity of dyspnea is crucial for determining the urgency of intervention.
2. By asking for a rating on a scale from 1 to 10, the nurse can quantify the level of distress the patient is experiencing.
3. This allows for a more objective assessment and helps in determining appropriate interventions.
4. Monitoring changes in the severity of dyspnea over time can also guide treatment effectiveness.
Summary of Incorrect Choices:
B. Asking about the last time the patient ate or drank is important for assessing possible contributing factors to dyspnea, but it does not directly address the immediate severity of the symptom.
C. Inquiring about nausea is relevant for a more comprehensive assessment, but it does not directly address the severity of dyspnea.
D. Asking about the potential need for medication is important, but it does not directly address the current level of dyspnea and may not be the immediate priority.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
- A. A 26-year-old woman who is 8 months pregnant.
- B. A 42-year-old man with gastroesophageal reflux disease.
- C. A 55-year-old woman who is 50 lb (23 kg) overweight.
- D. A 73-year-old man with type 2 diabetes mellitus.
Correct Answer: C
Rationale: The correct answer is C, a 55-year-old woman who is 50 lb overweight. Obesity is a major risk factor for obstructive sleep apnea (OSA) due to excess fat in the neck area that can obstruct the airway during sleep. This increases the likelihood of experiencing breathing pauses. Pregnancy (choice A) may cause temporary OSA due to hormonal changes, but it's not the greatest risk factor among the options provided. Gastroesophageal reflux disease (choice B) and type 2 diabetes mellitus (choice D) are associated with sleep disturbances, but they are not as directly linked to OSA as obesity.
A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?
- A. Simple mask
- B. Non-rebreather mask
- C. Face tent
- D. Nasal cannula
Correct Answer: B
Rationale: The correct answer is B: Non-rebreather mask. This device provides the highest concentration of oxygen among the choices, around 80-100%. In a client with difficulty breathing and low oxygen saturation, a high concentration of oxygen is crucial to quickly reverse hypoxemia. The non-rebreather mask ensures that the client is receiving the maximum amount of oxygen with each breath, improving oxygenation rapidly.
A: Simple mask delivers a lower concentration of oxygen and would not be sufficient for a client in distress.
C: Face tent does not provide a high concentration of oxygen and may not be effective in quickly reversing hypoxemia.
D: Nasal cannula delivers a lower concentration of oxygen compared to the non-rebreather mask and may not be enough to reverse manifestations in a client with significant difficulty breathing and low oxygen saturation.