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The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
- A. Blood gases
- B. Complete blood count
- C. Blood chemistry
- D. Serum alkaline phosphate
Correct Answer: A
Rationale: Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders.
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An 18-month-old child is brought to the emergency department by parents who explain that their child swallowed a watch battery. Radiologic studies show that the battery is in the lungs. Which area of lung is the battery most likely to be in?
- A. Right upper lung
- B. Left upper lung
- C. Right lower lung
- D. Left lower lung
Correct Answer: A
Rationale: Aspiration of foreign objects is more likely in the right main stem bronchus and right upper lung. The right mainstem bronchus is slightly higher and more vertical than the left, which is why foreign articles are often aspirated here first.
What is the difference between respiration and ventilation?
- A. Ventilation is the process of gas exchange.
- B. Ventilation is the movement of air in and out of the respiratory tract.
- C. Ventilation is the process of getting oxygen to the cells.
- D. Ventilation is the exchange of gases in the lung.
Correct Answer: B
Rationale: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
- A. Medulla oblongata, cerebellum, and heart rate
- B. Pons, cerebellum, and oxygen receptors
- C. Medulla oblongata, mitral valve, and central receptors
- D. Aortic arch, pons, and CO2 receptor sites
Correct Answer: D
Rationale: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.
A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
- A. The pons
- B. The frontal lobe
- C. Central sulcus
- D. Wernicke's area
Correct Answer: A
Rationale: The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.
The nurse is providing health education on the body's ability to exchange oxygen and carbon dioxide through the alveolar capillary membrane. Which statement, provided by the nurse, is most correct when asked about diffusion during inspiration?
- A. During inspiration, the concentration of oxygen is equal in both the alveoli and the capillaries.
- B. During inspiration, oxygen diffuses from the arterial system through to the alveolar capillary membrane.
- C. During inspiration, carbon dioxide provides the basis for all diffusion gradients.
- D. During inspiration, oxygen is greater in the alveoli than in the capillaries.
Correct Answer: D
Rationale: During inspiration, oxygen-rich air from the environment enters the pulmonary system. During inspiration, the concentration of inspired oxygen is higher in the alveoli than in the capillaries, causing diffusion from the alveoli to the capillaries. Thus, the concentration of oxygen is not equal in the alveoli and capillaries. There is no diffusion from the arterial system after the oxygen diffuses from the alveoli to the capillaries. Carbon dioxide does not provide the basis for all diffusion gradients.