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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The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions shouldn't the nurse include in the teaching plan?
- A. Place contaminated tissues in sealable plastic bag.
- B. Take medications exactly as directed.
- C. Implement airborne precautions.
- D. Wash hands frequently.
Correct Answer: C
Rationale: The correct answer is C because TB is transmitted through droplet transmission, not airborne. The nurse should include hand hygiene (D) to prevent spread through contact, proper medication adherence (B) to treat TB effectively, and proper disposal of contaminated materials (A) to prevent spread through fomites. Implementing airborne precautions is not necessary for TB, as it does not remain suspended in the air for long periods.
Comiculate are the paired cartilage of pharynx in which shape
- A. club shape
- B. horn shape
- C. Bate shape
- D. butterfly shape
Correct Answer: B
Rationale: The correct answer is B: horn shape. The corniculate cartilages are small, horn-shaped structures located on the apex of the arytenoid cartilages in the larynx. These cartilages play a role in supporting the vocal folds. The other choices (A, C, D) are incorrect because the corniculate cartilages are not club-shaped, bate-shaped, or butterfly-shaped. It is crucial to understand the anatomical structure and function of the corniculate cartilages to identify the correct shape accurately.
Reduction in respiratory surface of the lungs due to break down of partition in the alveoli is known as
- A. Asphyxia
- B. Bronchitis
- C. Asthma
- D. Emphysema
Correct Answer: D
Rationale: Emphysema is the correct answer because it is a condition where the alveoli walls break down, reducing the surface area for gas exchange in the lungs. This leads to difficulty in breathing. Asphyxia is suffocation due to lack of oxygen, not related to alveoli breakdown. Bronchitis is inflammation of the bronchial tubes, not alveoli damage. Asthma is a chronic condition affecting the airways, not specifically related to alveoli destruction. Therefore, emphysema is the most appropriate term for reduction in respiratory surface due to alveolar breakdown.
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.
A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.