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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: The correct answer is B: An adequate ventilation-perfusion ratio. Adequate gas exchange primarily depends on the matching of ventilation (air reaching the alveoli) and perfusion (blood flow to the alveoli). A mismatch in this ratio can lead to impaired gas exchange, resulting in hypoxia. Option A relates to gas movement efficiency but does not address the matching of ventilation and perfusion. Option C mentions shunted blood, which is not directly related to the ventilation-perfusion ratio. Option D is unrelated to gas exchange. In summary, the ventilation-perfusion ratio is crucial for optimal gas exchange, making it the correct choice.
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What dietary recommendation is often given to heart failure patients to manage their condition?
- A. High-sodium diet
- B. Low-fat diet
- C. Low-sugar diet
- D. Low-sodium diet
Correct Answer: D
Rationale: The correct answer is D: Low-sodium diet. Sodium can exacerbate fluid retention in heart failure patients, leading to increased workload on the heart. A low-sodium diet helps reduce fluid retention and manage symptoms. High-sodium diet (A) is detrimental to heart failure patients. Low-fat diet (B) and low-sugar diet (C) may be beneficial for overall health but are not specific recommendations for managing heart failure.
The nasal conchae epithelial surface serves to:
- A. Warm and moisten inhaled air, via air turbulence.
- B. Help filter dust and insects from the inhaled air
- C. Recapture moisture from exhaled air to preserve fluid.
- D. All of the above are correct.
Correct Answer: D
Rationale: Rationale: The nasal conchae increase surface area, causing air turbulence to warm, moisten, and filter inhaled air. This helps in preventing respiratory issues. Choice A is correct as it explains the primary function of the conchae. Choice B is incorrect as the primary function is not filtering. Choice C is incorrect as the conchae primarily warm and moisten inhaled air rather than recapture moisture from exhaled air. Overall, choice D is correct as it encompasses all the functions of the nasal conchae.
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met?
- A. 100% of meals being eaten by the client
- B. Intact skin behind the ears
- C. The client understanding the need for oxygen
- D. Unchanged weight for the past 3 days
Correct Answer: B
Rationale: The correct answer is B. Intact skin behind the ears indicates that the oxygen delivery device is fitted properly and not causing skin breakdown, ensuring client safety. A (meals being eaten) is not directly related to oxygen therapy outcomes. C (client understanding) is important but doesn't directly assess client safety with oxygen therapy. D (unchanged weight) is not a specific indicator of client safety with oxygen therapy.
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
- A. Increased temperature
- B. Absent breath sounds
- C. Productive cough
- D. Incisional discomfort
Correct Answer: B
Rationale: The correct answer is B: Absent breath sounds. This finding could indicate a pneumothorax, a serious complication post lung biopsy requiring immediate intervention. Absent breath sounds suggest air accumulation in the pleural space, causing lung collapse. Prompt action is crucial to prevent respiratory distress. Increased temperature (A) may indicate infection but not as urgent as addressing a pneumothorax. Productive cough (C) is common post-procedure. Incisional discomfort (D) is expected and can be managed with appropriate pain relief measures.
The nurse recognizes that a rising PaCO2 level in a COPD patient means that:
- A. There is more arterial oxygen available than is needed.
- B. The ventilation-perfusion ratio is becoming balanced.
- C. Respiratory acidosis has begun.
- D. The anticholinergics are effective.
Correct Answer: C
Rationale: Step-by-step rationale for why answer C is correct:
1. In COPD, impaired lung function leads to inadequate ventilation and CO2 retention.
2. Rising PaCO2 indicates inadequate CO2 removal, leading to respiratory acidosis.
3. Respiratory acidosis is characterized by low pH and high PaCO2 levels.
4. This condition can worsen COPD symptoms and lead to respiratory failure.
Summary: Option A is incorrect as rising PaCO2 indicates hypoxemia. Option B is incorrect as ventilation-perfusion imbalance worsens in COPD. Option D is incorrect as anticholinergics do not directly affect PaCO2 levels in COPD.