Nokea
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. The client rates pain as a 5/10 at the site of the procedure.
- B. A small amount of drainage from the site is noted.
- C. Pulse oximetry is 93% on 2 L of oxygen.
- D. The trachea is shifted toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because the trachea shifted towards the opposite side indicates a potential pneumothorax, a serious complication following thoracentesis. Immediate action is needed to prevent respiratory distress. Choices A and B are common post-procedural findings and may not require immediate action. Choice C, while indicating hypoxemia, does not pose an immediate threat compared to a tracheal deviation.
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Carbon monoxide
- A. has a very low affinity or attraction to hemoglobin.
- B. is unlikely to be transported by the circulatory system.
- C. is not the cause of death of people who breathe excessive amounts of automobile exhausts.
- D. can arise from cigarette smoke
Correct Answer: D
Rationale: The correct answer is D because carbon monoxide can indeed arise from cigarette smoke due to incomplete combustion of tobacco. This is supported by scientific evidence. Carbon monoxide has a high affinity for hemoglobin, so choice A is incorrect. It can be transported by the circulatory system, making choice B incorrect. Breathing excessive amounts of automobile exhaust containing carbon monoxide can lead to death, making choice C incorrect.
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.
The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
- A. Make inhalation longer than exhalation.
- B. Exhale through an open mouth.
- C. Use diaphragmatic breathing.
- D. Use chest breathing.
Correct Answer: C
Rationale: The correct answer is C: Use diaphragmatic breathing. Diaphragmatic breathing involves using the diaphragm to breathe deeply, allowing more air to enter the lungs and improving oxygenation. This is beneficial for clients with chronic bronchitis as it helps improve lung function and efficiency. Making inhalation longer than exhalation (Choice A) may lead to hyperventilation. Exhaling through an open mouth (Choice B) can lead to loss of carbon dioxide. Using chest breathing (Choice D) is less efficient and can exacerbate breathing difficulties in clients with chronic bronchitis. Diaphragmatic breathing is the most effective technique for improving breathing and should be emphasized in teaching.
A medical patient rings her call bell and expresses alarm to the nurse, stating, 'I've just coughed up this blood. That can't be good, can it?' How can the nurse best determine whether the source of the blood was the patient's lungs?
- A. Obtain a sample and test the pH of the blood, if possible.
- B. Try to see if the blood is frothy or mixed with mucus.
- C. Perform oral suctioning to see if blood is obtained.
- D. Swab the back of the patient's throat to see if blood is present.
Correct Answer: B
Rationale: The correct answer is B: Try to see if the blood is frothy or mixed with mucus. By observing if the blood is frothy or mixed with mucus, the nurse can determine if the source is more likely to be from the lungs, as blood from the lungs is often frothy due to air mixing with it during coughing. This observation helps differentiate between blood coming from the respiratory tract versus other sources in the body.
Incorrect choices:
A: Testing the pH of the blood does not directly indicate the source of the blood in this context.
C: Performing oral suctioning may not provide accurate information about the source of the blood.
D: Swabbing the back of the throat may not help determine if the blood is coming from the lungs as it could be from other sources in the upper respiratory tract.
Respiratory mechanism is controlled by
- A. Central nervous system
- B. Sympathetic nervous system
- C. Parasympathetic nervous system
- D. Autonomic nervous system
Correct Answer: A
Rationale: The correct answer is A: Central nervous system. The respiratory mechanism is controlled by the brainstem, specifically the medulla oblongata and pons. These areas of the central nervous system regulate breathing by monitoring levels of carbon dioxide and oxygen in the blood. The medulla sets the basic rhythm of breathing, while the pons helps fine-tune the breathing rate. Choices B, C, and D are incorrect because while the sympathetic and parasympathetic nervous systems are involved in regulating various bodily functions, they do not directly control the respiratory mechanism. The autonomic nervous system, which includes both the sympathetic and parasympathetic divisions, plays a role in involuntary functions like heart rate and digestion, but it is not the primary controller of breathing.