Nokea
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
- A. Their location over a specific area of the lung
- B. The volume of the sounds
- C. Whether they are heard on inspiration or expiration
- D. Whether or not they are continuous breath sounds
Correct Answer: A
Rationale: The correct answer is A because vesicular, bronchovesicular, and bronchial breath sounds are distinguished based on their location over specific areas of the lung. Vesicular sounds are soft and low-pitched and are heard over most of the lung fields, bronchovesicular sounds are intermediate in pitch and are heard over the major bronchi, and bronchial sounds are loud and high-pitched and are heard over the trachea and larynx. Choices B, C, and D are incorrect as the distinction between these breath sounds is not based on volume, inspiration or expiration, or continuity of the sounds.
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diaphragm relaxes and decrease thoracic space in which phase of respiration.
- A. inspiration
- B. expiration
- C. Pause
- D. both a and b
Correct Answer: B
Rationale: During expiration, the diaphragm relaxes, causing it to move upwards, which decreases the thoracic space. This leads to the expulsion of air from the lungs. In contrast, during inspiration, the diaphragm contracts and moves downwards, increasing the thoracic space to allow air to enter the lungs. Option C, Pause, does not involve any specific respiratory phase. Option D, both a and b, is incorrect because during inspiration, the diaphragm contracts and increases thoracic space. Therefore, the correct answer is B, expiration, as this phase specifically involves the relaxation of the diaphragm and the decrease in thoracic space.
In teaching a patient with hypertension about controlling the illness the nurse recognizes that?
- A. All patients with elevated BP need drug therapy.
- B. Obese persons must achieve a normal weight to lower BP.
- C. It is not necessary to limit salt in the diet if taking a diuretic.
- D. Lifestyle modifications are needed for all persons with elevated BP.
Correct Answer: D
Rationale: Rationale:
D is correct because lifestyle modifications, such as exercise and diet changes, are essential for managing hypertension. This approach can help lower blood pressure without the need for drug therapy. A is incorrect because not all patients with elevated BP require medication. B is incorrect as weight loss is beneficial but not the only factor in controlling BP. C is incorrect because limiting salt intake remains important even if taking a diuretic.
What is the name given to the respiratory ailment in which the bronchioles constrict severely?
- A. pleurisy
- B. emphysema
- C. bronchitis
- D. asthma
Correct Answer: D
Rationale: The correct answer is D: asthma. Asthma is a respiratory ailment characterized by severe constriction of the bronchioles due to inflammation and muscle contraction. This leads to difficulty breathing and wheezing. Pleurisy (A) is inflammation of the lining of the lungs, emphysema (B) is a long-term lung disease, and bronchitis (C) is inflammation of the bronchial tubes. Asthma specifically refers to the bronchioles constriction, making it the correct choice.
The impulse for voluntary muscles for forceful breathing starts in
- A. Medulla (Pons)
- B. Vagus nerve
- C. Cerebral hemispheres
- D. Spinal cord
Correct Answer: C
Rationale: The correct answer is C: Cerebral hemispheres. The impulse for voluntary muscles for forceful breathing originates in the cerebral hemispheres where conscious control over breathing is regulated. The cerebral cortex sends signals to the respiratory muscles to increase or decrease breathing effort based on the body's needs. The other choices are incorrect because:
A: Medulla (Pons) - This region of the brainstem is responsible for automatic breathing control, not voluntary forceful breathing.
B: Vagus nerve - The vagus nerve is not directly involved in initiating voluntary breathing movements.
D: Spinal cord - While the spinal cord plays a role in coordinating some aspects of breathing, it is not the primary center for voluntary forceful breathing control.
Which action should you delegate to the experienced nursing assistant?
- A. Assess the client's respiratory status every 4 hours.
- B. Take vital signs and pulse oximetry reading every 4 hours.
- C. Check ventilator setting to make sure they are as prescribed.
- D. Observe client’s need for suctioning every 2 hours.
Correct Answer: B
Rationale: The correct answer is B. Taking vital signs and pulse oximetry readings is a routine task suitable for a nursing assistant. Assessing respiratory status (A) and checking ventilator settings (C) require RN-level skills. Observing suctioning needs (D) is less critical and often done by RNs.