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: Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Impairment of normal diffusion is a less common cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis only occurs from breathing compressed air.
You may also like to solve these questions
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?
- A. An appropriate perfusion-diffusion ratio
- B. An adequate ventilation-perfusion ratio
- C. Adequate diffusion of gas in shunted blood
- D. Appropriate blood nitrogen concentration
Correct Answer: B
Rationale: Adequate gas exchange depends on an adequate ventilation-perfusion ratio. There is no perfusion-diffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen.
The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be ordered to assess for what in this patient?
- A. Alveolar dysfunction
- B. Forced vital capacity
- C. Tidal volume
- D. Chest wall invasion
Correct Answer: D
Rationale: MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. Imaging would not focus on the alveoli since the problem is in the bronchi. A static image such as MRI cannot inform PFT.
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
- A. Expiratory wheezes
- B. Inspiratory wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: D
Rationale: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids?
- A. Presence of a cough and gag reflex
- B. Absence of nausea
- C. Ability to demonstrate deep inspiration
- D. Oxygen saturation of 92%
Correct Answer: A
Rationale: After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.
The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity?
- A. A barrel chest
- B. A funnel chest
- C. A pigeon chest
- D. Kyphoscoliosis
Correct Answer: B
Rationale: A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs. A barrel chest is characterized by an increase in the anteroposterior diameter of the thorax and is a result of overinflation of the lungs. A pigeon chest occurs as a result of displacement of the sternum and includes an increase in the anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.