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The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
- A. The nursing assistant is assisting the client to a semi-Fowler's position.
- B. The nursing assistant is assisting the client to the side of the bed to use a urinal.
- C. The nursing assistant is pouring a glass of water to wet the client's mouth.
- D. The nursing assistant is asking a question requiring a verbal response.
Correct Answer: C
Rationale: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post-procedure period.
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The nurse is providing health education on the body's ability to exchange oxygen and carbon dioxide through the alveolar capillary membrane. Which statement, provided by the nurse, is most correct when asked about diffusion during inspiration?
- A. During inspiration, the concentration of oxygen is equal in both the alveoli and the capillaries.
- B. During inspiration, oxygen diffuses from the arterial system through to the alveolar capillary membrane.
- C. During inspiration, carbon dioxide provides the basis for all diffusion gradients.
- D. During inspiration, oxygen is greater in the alveoli than in the capillaries.
Correct Answer: D
Rationale: During inspiration, oxygen-rich air from the environment enters the pulmonary system. During inspiration, the concentration of inspired oxygen is higher in the alveoli than in the capillaries, causing diffusion from the alveoli to the capillaries. Thus, the concentration of oxygen is not equal in the alveoli and capillaries. There is no diffusion from the arterial system after the oxygen diffuses from the alveoli to the capillaries. Carbon dioxide does not provide the basis for all diffusion gradients.
An 18-month-old child is brought to the emergency department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?
- A. Right upper lung
- B. Left upper lung
- C. Right lower lung
- D. Left lower lung
Correct Answer: A
Rationale: Aspiration of foreign objects is more likely in the right main stem bronchus and right upper lung. The right mainstem bronchus is slightly higher and more vertical than the left, which is why foreign articles are often aspirated here first.
A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates improvement in an area of the lung affected by the infection?
- A. Lung fields documented as clear.
- B. Palpable vibrations over the chest wall when the client speaks.
- C. Decreased fremitus when the client feels the vibration in their chest.
- D. Dull sounds percussed over the lung tissue.
- E. Bronchial sounds heard only in the affected area.
Correct Answer: A
Rationale: To determine if the client's respiratory infection has resolved, the nurse should assess the client's normal respiratory status. Lungs will return to clear breath sounds. Palpable vibrations will be felt ,as they may be normal if there is no infection in the lungs. A client with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe. A decreased fremitus would indicate resolution of infection. Bronchial sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks '99.' Dull percussed sounds indicate an area of consolidation or infection.
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
- A. Medulla oblongata, cerebellum, and heart rate
- B. Pons, cerebellum, and oxygen receptors
- C. Medulla oblongata, mitral valve, and central receptors
- D. Aortic arch, pons, and CO2 receptor sites
Correct Answer: D
Rationale: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.
The nurse is caring for a client who states, 'I am really worried about the thoracentesis. I know I won't be able to sleep tonight.' Which statement is most helpful to the client at this time?
- A. Tell me what you are worried about.'
- B. Is there something that I can help you with?'
- C. Is there someone that you would like me to call to be with you?'
- D. The physician will see you before the procedure and can answer any questions.'
Correct Answer: A
Rationale: A thoracentesis is performed by inserting a needle into the wall under local anesthesia. The thoracentesis is often done at the bedside. Providing support to the client before, during, and after the treatment is a nursing responsibility. When the client expresses being worried, asking an open-ended question promotes communication and is most therapeutic. Asking if there is something that a nurse can do is a closed-ended question. Asking about calling someone to be with the client makes the nurse seem uninterested. Talking with the physician closes communication with the nurse, making the nurse seem uninterested.