Nokea
The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?
- A. Urine output is 500 mL during an 8-hour shift.
- B. Tremors are noted in the fingers when the patient extends the arms.
- C. The client reports a headache with pain at level 7
- D. The client cannot move the left arm when asked to do so.
Correct Answer: D
Rationale: The correct answer is D because the inability to move the left arm could indicate a neurological deficit or stroke, which is a critical finding that requires immediate medical attention in a hypertensive emergency. This could indicate a potential life-threatening condition that needs urgent intervention to prevent further complications.
A: Urine output is important but not as critical as potential neurological deficits in this scenario.
B: Tremors in the fingers are concerning but not as urgent as a potential neurological deficit.
C: Headache at level 7 is significant but not as critical as a neurological deficit that could indicate a stroke.
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For a male client with an endotracheal (ET) tube, which nursing action is most essential?
- A. Auscultating the lungs for bilateral breath sounds.
- B. Turning the client from side to side every 2 hours.
- C. Monitoring serial blood gas values every 4 hours.
- D. Providing frequent oral hygiene.
Correct Answer: A
Rationale: The correct answer is A: Auscultating the lungs for bilateral breath sounds. This is the most essential nursing action for a male client with an endotracheal tube because it ensures proper placement of the tube and adequate ventilation. By auscultating the lungs, the nurse can assess for any potential complications such as tube displacement, pneumothorax, or mucus plugging. This action helps in early detection of respiratory issues and prompt intervention if needed.
Summary:
- Choice B (Turning the client from side to side every 2 hours) is important for preventing pressure ulcers but not as critical as assessing breath sounds.
- Choice C (Monitoring serial blood gas values every 4 hours) is important for evaluating respiratory status but does not provide immediate information on tube placement.
- Choice D (Providing frequent oral hygiene) is important for preventing infections but does not directly assess the client's respiratory status with an ET tube.
Which of the following does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Friction rub
- C. Expiratory wheezes
- D. Fluid in the involved area
Correct Answer: D
Rationale: The correct answer is D. Fluid in the pleural space muffles breath sounds and may be noted during auscultation. A (pronounced breath sounds) is incorrect as they are diminished in pleural effusion. B (friction rub) occurs in pleuritis, not effusion. C (expiratory wheezes) indicates airway obstruction, not fluid accumulation.
The combination of Hemoglobin with Oxygen in the blood can be promoted by
- A. Decreasing O2 concentration
- B. Increasing O2 concentration
- C. Increasing CO2 concentration
- D. Decreasing CO2 concentration
Correct Answer: B
Rationale: The correct answer is B: Increasing O2 concentration. When O2 concentration increases, it promotes the binding of oxygen to hemoglobin in the blood through the process of oxygenation. This results in the formation of oxyhemoglobin, which enhances oxygen transport in the blood.
Summary:
- A: Decreasing O2 concentration would hinder the binding of oxygen to hemoglobin, reducing oxygen transport efficiency.
- C: Increasing CO2 concentration would lead to the formation of carbaminohemoglobin, not oxyhemoglobin.
- D: Decreasing CO2 concentration would not directly promote the binding of oxygen to hemoglobin.
The lungs are covered by a two-layer membrane called the:
- A. pleura.
- B. diaphragm.
- C. respiratory membrane.
- D. intercostal muscles.
Correct Answer: A
Rationale: The correct answer is A: pleura. The pleura is a two-layered membrane that covers the lungs. The outer layer is called the parietal pleura, which lines the chest wall, and the inner layer is called the visceral pleura, which covers the lungs themselves. This double-layered structure helps to protect and cushion the lungs during breathing movements.
Summary of incorrect choices:
B: The diaphragm is a dome-shaped muscle located below the lungs that plays a role in breathing but does not cover the lungs.
C: The respiratory membrane refers to the interface where gas exchange occurs in the alveoli, not the covering of the lungs.
D: The intercostal muscles are located between the ribs and assist in breathing but do not cover the lungs.
In the lungs
- A. PCO2 in the alveoli is the same as that in the capillaries
- B. PO2 in the alveoli is the same as that in the capillaries
- C. PCO2 in the alveoli is higher than that in the capillaries
- D. PCO2 in the alveoli is lower than that in the capillaries
Correct Answer: D
Rationale: The correct answer is D because in the lungs, during gas exchange, carbon dioxide (CO2) is removed from the blood and exhaled. This leads to a lower PCO2 in the alveoli compared to the capillaries. The concentration gradient drives the diffusion of CO2 from the capillaries to the alveoli. Options A and B are incorrect because the partial pressure of CO2 (PCO2) and oxygen (PO2) differ between the alveoli and capillaries due to gas exchange. Option C is also incorrect as PCO2 is lower in the alveoli to facilitate the removal of CO2 from the blood.