Nokea
The Hering-Breuer reflex
- A. functions to increase ventilation with changes in blood pressure
- B. alters pulmonary ventilation when the PO2 changes
- C. alters pulmonary ventilation when the PCO2 changes
- D. protects the lungs from damage due to overinflation
Correct Answer: D
Rationale: The correct answer is D because the Hering-Breuer reflex is a protective mechanism that prevents lung damage from overinflation by inhibiting inspiration. When the lungs are at risk of overinflation, stretch receptors in the lung tissue send signals to the brainstem to reduce or stop inspiration, preventing excessive stretching of the alveoli. Choices A, B, and C are incorrect as the Hering-Breuer reflex is not involved in changes in blood pressure, PO2, or PCO2 regulation.
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A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage
- A. a headache
- B. and difficulty with vision. What action would the nurse take next?
- C. Collect the nasal drainage on a piece of filter paper.
- D. Encourage the client to blow his or her nose.
Correct Answer: A
Rationale: The correct answer is A: a headache. Nasal drainage with a nasal fracture can indicate a potential cerebrospinal fluid leak, leading to a headache. This symptom requires immediate attention to rule out serious complications. Choice B is incorrect because difficulty with vision is not typically associated with a nasal fracture. Choice C is incorrect as collecting drainage on filter paper does not address the client's symptoms. Choice D is incorrect as blowing the nose can exacerbate the fracture and should be avoided.
The nurse recognizes that additional teaching is needed when the patient with asthma says
- A. a. I should exercise every day if my symptoms are controlled.
- B. b. I may use over-the-counter bronchodilator drugs occasionally if I develop chest tightness.
- C. c. I should inform my spouse about my medications and how to get help if I have a severe asthma attack.
- D. A diary to record my medication use, symptoms, peak expiratory flow rates, and activity levels will help in adjusting my therapy.
Correct Answer: D
Rationale: Additional teaching is needed when the patient mentions using over-the-counter bronchodilator drugs occasionally. This is not recommended as it can mask underlying issues and delay proper treatment.
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea,tachycardia and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement ALL priority interventions EXCEPT?
- A. Administer oxygen
- B. Administer furosemide (diuretic)
- C. Transport to coronary care unit
- D. Obtain stat Hepatic Panel
Correct Answer: C
Rationale: Rationale: Option C, transporting the client to the coronary care unit, is not the priority intervention because the client is presenting with acute pulmonary edema, a sign of worsening heart failure. Administering oxygen (Option A) is crucial to improve oxygenation. Administering furosemide (Option B) helps reduce fluid overload. Obtaining a stat Hepatic Panel (Option D) may be necessary to assess liver function due to medication side effects. However, immediate actions to address respiratory distress and tachycardia take precedence over moving the client to another unit.
Which of the following are risk factors of laryngeal cancer?
- A. Acute laryngitis
- B. Tobacco use
- C. Caffeine use
- D. Sleep apnea
Correct Answer: B
Rationale: The correct answer is B. Tobacco use is a well-established risk factor for laryngeal cancer. A (acute laryngitis) is a temporary condition and not a risk factor. C (caffeine use) has no proven link to laryngeal cancer. D (sleep apnea) is unrelated.
The client with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which action is appropriate to delegate to the experienced LPN/LVN under your supervision?
- A. Observe how well the client performs pursed-lip breathing.
- B. Plan a nursing care regimen that gradually increases activity tolerance.
- C. Assist the client with basic activities of daily living (ADLs).
- D. Consult with physical therapy about reconditioning exercises.
Correct Answer: C
Rationale: The correct answer is C. Assisting with ADLs is a routine task suitable for an LPN/LVN. Observing pursed-lip breathing (A) and planning care regimens (B) are more advanced tasks. Consulting physical therapy (D) requires RN-level decision-making.