Nokea
The nurse is suctioning a client who is unable to expectorate respiratory secretions. At which point does the nurse expect the client to experience coughing?
- A. When the catheter reaches the back of the pharynx
- B. When the catheter enters the main bronchus of the lung
- C. When the catheter reaches the point of the carina
- D. When the catheter tickles the uvula
Correct Answer: C
Rationale: Upon the catheter stimulating the carina, coughing and even bronchospasm may occur. Productive secretions may be loosened and eliminated via the suction catheter. When the catheter reaches the back of the pharynx near the uvula, the gag reflex is initiated. The suction catheter does not reach the entrance of the lung.
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The nurse is caring for a client with hypoxemia of unknown cause. Which oxygen transport consideration(s) does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.
- A. Oxygen is dissolved.
- B. High blood pressure disrupts oxygen transport.
- C. Oxyhemoglobin circulates to the body tissue.
- D. All systemic oxygen is available for diffusion.
- E. Adequate red blood cells are needed for oxygen transport.
Correct Answer: A,C,E
Rationale: Oxygen transport occurs by dissolving oxygen in the water in the plasma and combining oxygen with red blood cells (oxyhemoglobin). Normal red blood cell count is needed for oxygen transport. High blood pressure does not disrupt transport unless there is disruption in perfusion via a bleeding or occlusion. Dissolved oxygen is the only form which can diffuse across cell membranes.
The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about?
- A. Raised temperature in the affected limb
- B. Excessive capillary refill
- C. Absent distal pulses
- D. Flushed feeling in the client
Correct Answer: C
Rationale: When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. Absent distal pulses may indicate damage to the artery or a clot. When the contrast medium is infused, the client will sense a warm, flushed feeling.
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.
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.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. On lung assessment, which adventitious breath sounds are anticipated?
- A. Crackles
- B. Sonorous wheezes
- C. Rubs
- D. Sibilant wheezes
Correct Answer: D
Rationale: A decrease in airway diameter, such as in asthma, produces breath sounds of wheezes. Wheezes may be sibilant (hissing or whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. Sonorous wheezes (formerly called rhonchi) are lower pitched and are heard in the trachea and bronchi. Sonorous wheezes are coarse, rattling sounds similar to snoring usually caused by secretion in the bronchial tree. Crackles, also called rales, are crackling or rattling sounds signifying fluid or exudate in the lung fields. Rubs are secretions that can be heard in the large airway.