Nokea
The client with COPD tells the nursing assistant that she did not get her annual flu shot this year and has not had a pneumonia vaccination. You will be sure to instruct the nursing assistant to report which of the following?
- A. Blood pressure 152/84
- B. Respiratory rate 27/minute
- C. Heart rate 92/minute
- D. Oral temperature 101.2°F
Correct Answer: D
Rationale: The correct answer is D. A fever of 101.2°F is significant and warrants immediate reporting. Blood pressure (A), respiratory rate (B), and heart rate (C) are within normal limits for someone with COPD.
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The client with which of the following types of lung cancer metastasizes quickly?
- A. Adenocarcinoma
- B. Oat cell
- C. Squamous cell
- D. Bronchial carcinoids
Correct Answer: B
Rationale: The correct answer is B: Oat cell. Oat cell (small cell) lung cancer metastasizes quickly due to its aggressive nature, high growth rate, and early dissemination to distant sites. This type of cancer is known for its rapid spread to other organs, leading to poor prognosis. Adenocarcinoma, squamous cell, and bronchial carcinoids have a slower metastatic rate compared to oat cell lung cancer. Adenocarcinoma tends to metastasize to the lymph nodes and other organs over time, while squamous cell typically spreads locally within the lung tissue. Bronchial carcinoids are slow-growing tumors with a lower propensity for rapid metastasis compared to oat cell lung cancer.
Identify the inconsistent value at sea level
- A. Alveolar pCO2 = 40mmHg
- B. Alveolar pO2 = 100mmHg
- C. Alveolar PH2O = 47mmHg
- D. pO2 of inspired air = 130mmHg
Correct Answer: D
Rationale: The correct answer is D because at sea level, the pO2 of inspired air is around 159mmHg, not 130mmHg. This is due to the partial pressure of oxygen being higher at sea level. Alveolar pCO2, pO2, and PH2O values are consistent with normal values at sea level. Therefore, D is the inconsistent value.
Which action should the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new client?
- A. Deflate the BP cuff at a rate of 30 mm Hg per second.
- B. Have the client sit in a chair with the feet flat on the floor.
- C. Assist the client to the supine position for BP measurements.
- D. Obtain two BP readings in the dominant arm and average the results.
Correct Answer: B
Rationale: The correct answer is B because having the client sit in a chair with feet flat on the floor is the recommended position for accurate baseline BP measurement. This position ensures proper alignment of the heart and the cuff, reducing errors caused by arm positioning. Choice A is incorrect as deflating the cuff at a rate of 30 mm Hg per second is not related to obtaining an accurate baseline BP measurement. Choice C is incorrect as measuring BP in the supine position can lead to inaccurate readings due to changes in blood flow dynamics. Choice D is incorrect as obtaining two BP readings in the dominant arm and averaging the results may not provide an accurate baseline BP measurement due to variations in BP readings between arms.
The nurse is completing a patient's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?
- A. Have you ever been employed in a factory, smelter, or mill?
- B. Does anyone in your family have any form of lung disease?
- C. Do you currently smoke, or have you ever smoked?
- D. Have you ever lived in an area that has high levels of air pollution?
Correct Answer: C
Rationale: The correct answer is C: "Do you currently smoke, or have you ever smoked?" Smoking is the most significant risk factor for respiratory diseases, including lung cancer, chronic obstructive pulmonary disease, and emphysema. Asking about smoking history is crucial in assessing lung disease risk.
Rationale:
1. Smoking is the leading cause of preventable death worldwide.
2. Smoking damages the lungs and increases the risk of developing various respiratory conditions.
3. Current and past smoking status helps determine the level of risk for lung disease.
4. Tobacco smoke contains harmful chemicals that can lead to lung damage over time.
Summary:
A: Occupational exposure is a risk factor, but smoking has a stronger association with respiratory diseases.
B: Family history is relevant but not as directly linked to individual behavior and risk as smoking.
D: Air pollution can contribute to lung issues, but personal smoking history has a more direct impact on lung health.
The cessation of smoking
- A. can reduce the risk of stillbirth
- B. reduces the chances of cancer
- C. reduces the chances of coronary disease
- D. all of the above
Correct Answer: D
Rationale: The correct answer is D, all of the above. Cessation of smoking reduces the risk of stillbirth by improving fetal health. It also reduces the chances of cancer by decreasing exposure to carcinogens. Additionally, quitting smoking decreases the risk of coronary disease by improving heart health. Therefore, all the choices are correct as they highlight different positive outcomes of quitting smoking.