Nokea
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
- A. Tickle the back of the throat to produce the gag reflex.
- B. Drink 8 oz of water to thin the secretions for expectoration.
- C. Use the secretions present in the oral cavity.
- D. Take deep breaths and cough forcefully.
Correct Answer: D
Rationale: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.
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A nurse is performing a physical assessment on a client who has a history of a respiratory infection. Which documentation, completed by the nurse, indicates improvement in an area of the lung affected by the infection?
- A. Lung fields documented as clear.
- B. Palpable vibrations over the chest wall when the client speaks.
- C. Decreased fremitus when the client feels the vibration in their chest.
- D. Dull sounds percussed over the lung tissue.
- E. Bronchial sounds heard only in the affected area.
Correct Answer: A
Rationale: To determine if the client's respiratory infection has resolved, the nurse should assess the client's normal respiratory status. Lungs will return to clear breath sounds. Palpable vibrations will be felt ,as they may be normal if there is no infection in the lungs. A client with consolidation of a lobe of the lung from pneumonia has increased tactile fremitus over that lobe. A decreased fremitus would indicate resolution of infection. Bronchial sounds will be noted over the upper lung fields. An increased fremitus is noted as the client speaks '99.' Dull percussed sounds indicate an area of consolidation or infection.
The nurse is studying for a physiology test over the respiratory system. What should the nurse know about central chemoreceptors in the medulla?
- A. They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.
- B. They respond to changes in the O2 levels in the brain.
- C. They respond to changes in CO2 levels in the brain.
- D. They respond to changes in O2 levels and bicarbonate levels in the cerebrospinal fluid.
Correct Answer: A
Rationale: Central chemoreceptors in the medulla respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid. Central chemoreceptors do not respond to changes in the O2 levels in the brain, changes in CO2 levels in the brain, changes in O2 levels, and bicarbonate levels in the cerebrospinal fluid.
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
- A. The nursing assistant is assisting the client to a semi-Fowler's position.
- B. The nursing assistant is assisting the client to the side of the bed to use a urinal.
- C. The nursing assistant is pouring a glass of water to wet the client's mouth.
- D. The nursing assistant is asking a question requiring a verbal response.
Correct Answer: C
Rationale: When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client. The client may need assistance following the procedure for activity and ambulation but this is not restricted in the post-procedure period.
A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?
- A. The pons
- B. The frontal lobe
- C. Central sulcus
- D. Wernicke's area
Correct Answer: A
Rationale: The inspiratory and expiratory centers in the medulla oblongata and pons control the rate and depth of ventilation. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.
What is the difference between respiration and ventilation?
- A. Ventilation is the process of gas exchange.
- B. Ventilation is the movement of air in and out of the respiratory tract.
- C. Ventilation is the process of getting oxygen to the cells.
- D. Ventilation is the exchange of gases in the lung.
Correct Answer: B
Rationale: Ventilation is the actual movement of air in and out of the respiratory tract. Respiration is the exchange of oxygen and CO2 between atmospheric air and the blood and between the blood and the cells.