Nokea
The covering of the lung is called
- A. Pericardium
- B. Perichondrium
- C. Pleural membrane/ pleura
- D. Peritoneum
Correct Answer: C
Rationale: The correct answer is C: Pleural membrane/pleura. The pleural membrane is a double-layered serous membrane that covers the lungs. The visceral pleura is attached to the lung surface, while the parietal pleura lines the chest cavity. This arrangement helps reduce friction and allows the lungs to expand during breathing.
A: Pericardium covers the heart, not the lungs.
B: Perichondrium covers cartilage, not the lungs.
D: Peritoneum covers abdominal organs, not the lungs.
Therefore, the correct choice is C because it specifically refers to the covering of the lungs.
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Spirometry is used
- A. To detect the amount of Hemoglobin
- B. To detect the air flow through the respiratory system
- C. To check the respiratory quotient
- D. None of these
Correct Answer: B
Rationale: The correct answer is B: To detect the air flow through the respiratory system. Spirometry measures lung function by assessing the volume of air inhaled and exhaled. It helps in diagnosing respiratory conditions like asthma or COPD. Choice A is incorrect because spirometry does not measure hemoglobin levels. Choice C is incorrect as spirometry does not determine the respiratory quotient, which relates to metabolic processes. Choice D is incorrect as spirometry is used for assessing respiratory function.
When the diaphragm and external intercostals muscles contract, which of the following actions does NOT occur?
- A. air moves into the lung
- B. the intrapleural pressure increases
- C. the diaphragm moves inferiorly
- D. the intrapulmonary pressure decreases
Correct Answer: B
Rationale: When the diaphragm and external intercostals contract, the thoracic cavity expands, causing the lungs to expand and the intrapulmonary pressure to decrease (choice D). This decrease in pressure allows air to flow into the lungs (choice A). The diaphragm moves inferiorly during contraction, not superiorly (choice C). The intrapleural pressure actually decreases when these muscles contract, not increases, due to increased thoracic volume and decreased intrapleural pressure acting as a suction to keep the lungs inflated (choice B). Therefore, the correct answer is B, as the intrapleural pressure actually decreases when the diaphragm and external intercostals contract.
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a few days ago" and shows the nurse the results of what the client calls an allergy test" as shown below: The reddened area is firm. What action by the nurse is best?
- A. Call the primary health care provider's office to request records.
- B. Immediately place the client on Airborne Precautions.
- C. Prepare to begin administration of intravenous antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Prepare to begin administration of intravenous antibiotics. This is the best action because the client is suspected of having pneumonia, which is commonly treated with antibiotics. The nurse should prepare to start IV antibiotics to address the infection promptly.
Choice A is incorrect because requesting records from the primary health care provider's office may delay treatment. Choice B is incorrect because airborne precautions are not necessary for suspected pneumonia. Choice D is incomplete and does not provide a clear action plan for addressing the client's condition.
The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that
the level of drainage has not increased over the last 3 hours. After assessing the patient’s
respiratory status, what should the nurse do next?
- A. Raise the system above the patient's heart.
- B. Check the tubing for kinks.
- C. Reposition the patient.
- D. Notify the physician.
Correct Answer: B
Rationale: The correct answer is B: Check the tubing for kinks. This is the best next step because stagnant drainage could be caused by a kink in the tubing, obstructing proper drainage. By checking for kinks, the nurse ensures proper functioning of the drainage system, preventing potential complications such as fluid buildup or infection.
Raising the system above the patient's heart (A) may not address the underlying issue of kinked tubing. Repositioning the patient (C) may not be necessary if the drainage is not related to patient positioning. Notifying the physician (D) should be done after checking the tubing for kinks, as it is important to troubleshoot and address the issue promptly.
While assessing an acutely ill patient's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?
- A. Eupnea
- B. Apnea
- C. Biot's respiration
- D. Cheyne-Stokes
Correct Answer: C
Rationale: The correct answer is C: Biot's respiration. Biot's respiration is characterized by regular breathing interrupted by periods of apnea. In this scenario, the nurse observed normal breaths followed by a 20-second episode of apnea, which aligns with Biot's respiration. It is crucial to document this finding accurately to ensure appropriate care.
Incorrect answers:
A: Eupnea refers to normal breathing without any interruptions or irregularities. The presence of apnea in the scenario rules out eupnea.
B: Apnea would be an incomplete assessment as it does not capture the alternating pattern of normal breaths and apnea observed in Biot's respiration.
D: Cheyne-Stokes breathing involves a cyclical pattern of gradually increasing and decreasing breathing rates, which is not evident in the scenario described.