Nokea
Select all the correct options that represent the pathophysiology of an asthma attack.
- A. The smooth muscle surrounding the alveoli constricts, limiting oxygenation.
- B. The mucosa lining experiences severe inflammation.
- C. The goblet cells within the mucosa lining produce excessive amounts of mucous.
- D. Too much carbon dioxide is exhaled due to hyperventilation and the patient experiences respiratory alkalosis.
Correct Answer: B,C
Rationale: Asthma involves inflammation of the airway mucosa and excessive mucus production by goblet cells. Smooth muscle constriction occurs in bronchioles, not alveoli, and hyperventilation typically leads to respiratory acidosis due to CO2 retention.
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The charge nurse is assigning clients for the shift. Which client should be assigned to the new graduate nurse?
- A. The client diagnosed with cancer of the lung who has chest tubes.
- B. The client diagnosed with laryngeal spasms who has stridor.
- C. The client diagnosed with laryngeal cancer who has multiple fistulas.
- D. The client who is two (2) hours post-partial laryngectomy.
Correct Answer: A
Rationale: Chest tubes for lung cancer (A) are stable for a new graduate. Stridor (B), fistulas (C), and recent laryngectomy (D) require experienced care due to airway and complication risks.
Before suctioning, the nurse attaches a pulse oximeter to the client's finger. Which nursing actions are appropriate at this time? Select all that apply.
- A. Remove the client's fingernail polish.
- B. Place the sensor and receiver opposite to each other on the client's finger.
- C. Connect the cable to the oximeter.
- D. Set the SpO2 alarms between 95% and 100%.
- E. Notify the physician each time an alarm sounds.
- F. Relocate the spring-loaded sensor periodically.
Correct Answer: A, B, C, F
Rationale: Removing nail polish, positioning the sensor correctly, connecting the cable, and relocating the sensor periodically ensure accurate pulse oximetry readings.
After the bronchoscopy, what should the nurse closely monitor?
- A. The client's level of consciousness
- B. The client's oral status
- C. The client's respiratory effort
- D. The client's ability to speak
Correct Answer: C
Rationale: Monitoring respiratory effort is critical post-bronchoscopy to detect complications like airway obstruction or pneumothorax.
You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?
- A. Ethambutol
- B. Streptomycin
- C. Isoniazid
- D. Rifampin
Correct Answer: D
Rationale: This medication will cause body fluids to turn orange.
An adult is being treated with isoniazid (INH) and streptomycin for active tuberculosis. Which of the following symptoms would suggest a toxic effect of INH?
- A. Paroxysmal tachycardia
- B. Erythema multiforme
- C. Peripheral neuritis
- D. Tinnitus and deafness
Correct Answer: C
Rationale: Peripheral neuritis is a known toxic effect of isoniazid due to its interference with vitamin B6 metabolism.