Nokea
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what?
- A. Nitrogen narcosis
- B. Infection
- C. Impaired diffusion
- D. Shunting
Correct Answer: D
Rationale: The correct answer is D: Shunting. Hypoxia after a colon resection is likely due to shunting, which is a condition where blood bypasses the normal oxygenation process in the lungs, leading to decreased oxygen levels in the blood. Shunting can occur due to factors such as collapsed alveoli or blood vessel blockages.
Nitrogen narcosis (A) is not related to hypoxia but rather occurs in scuba divers exposed to high partial pressures of nitrogen. Infection (B) may cause fever and inflammation but is not the primary cause of hypoxia in this scenario. Impaired diffusion (C) refers to issues with gas exchange in the alveoli and is not the most likely cause of hypoxia after a colon resection.
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The primary chemical stimulus for breathing is the concentration of
- A. carbon monoxide in the blood
- B. carbon dioxide in the blood
- C. oxygen in the blood
- D. carbonic acid in the blood
Correct Answer: B
Rationale: The correct answer is B: carbon dioxide in the blood. In the body, carbon dioxide levels are monitored by chemoreceptors in the brainstem. When carbon dioxide levels rise, it triggers an increase in breathing rate to expel excess carbon dioxide and restore the balance of gases in the blood. This process is known as the respiratory drive. Carbon monoxide (A) is a toxic gas that interferes with oxygen transport but does not directly affect breathing stimulus. Oxygen (C) levels in the blood are important for maintaining tissue oxygenation but do not directly regulate breathing. Carbonic acid (D) is a product of carbon dioxide and water, and its levels do not directly stimulate breathing.
The nurse is caring for a client who is one hour post cardiac catheterization. What task should the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?
- A. Teach the patient about the post procedure plan of care.
- B. Perform the initial assessment of the catheter insertion site.
- C. Give the scheduled lipid-lowering medication.
- D. Titrate the diltiazem infusion according to the agency protocol.
Correct Answer: C
Rationale: The correct answer is C: Give the scheduled lipid-lowering medication. LPN/VNs can administer medications, including lipid-lowering drugs, under the supervision of a registered nurse. Teaching (choice A) requires a higher level of critical thinking and education, which is typically done by an RN. Performing an initial assessment (choice B) requires advanced assessment skills that an LPN/VN may not have. Titration of medications (choice D) involves adjusting dosages based on specific parameters, which is beyond the scope of practice for an LPN/VN.
When examining the posterior pharynx and tonsils, which of the following objective data does the nurse note?
- A. Difficulty in sneezing
- B. Suppressed gag reflex
- C. Deformities
- D. Inflammation
Correct Answer: D
Rationale: The correct answer is D. Inflammation is a key finding during examination of the posterior pharynx and tonsils, especially in infections such as tonsillitis. A (difficulty in sneezing) is unrelated to pharyngeal assessment. B (suppressed gag reflex) might indicate neurological issues but isn't typically noted during routine exams. C (deformities) is rare unless there's structural abnormality.
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
- A. Impaired gas exchange
- B. Collapsed bronchial structures
- C. Necrosis of the alveoli
- D. Closed bronchial tree
Correct Answer: A
Rationale: Step 1: Lower respiratory tract infection affects the lungs where gas exchange occurs.
Step 2: Infections can lead to inflammation and fluid buildup in the lungs.
Step 3: This impairs the exchange of oxygen and carbon dioxide.
Step 4: Impaired gas exchange can lead to hypoxemia and respiratory distress.
Step 5: Therefore, the correct answer is A: Impaired gas exchange. Other choices are incorrect because they do not directly relate to the physiological consequences of a lower respiratory tract infection.
The partial pressure of carbon dioxide in the interstitial space of peripheral tissues is approximately
- A. 35 mm Hg
- B. 45 mm Hg
- C. 55 mm Hg
- D. 70 mm Hg
Correct Answer: B
Rationale: The correct answer is B (45 mm Hg) because the partial pressure of carbon dioxide in the interstitial space of peripheral tissues is around 40-45 mm Hg. This value is higher than in the arterial blood (around 40 mm Hg) due to the production of CO2 by tissues. Choice A (35 mm Hg) is too low for interstitial CO2 levels. Choice C (55 mm Hg) and D (70 mm Hg) are too high and not consistent with normal physiological values. Overall, the correct answer aligns with the typical range of interstitial CO2 pressure in peripheral tissues.