Nokea
The nurse supervises unlicensed assistive personnel (UAP) providing care for a client who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene?
- A. UAP assists the client to ambulate to the bathroom.
- B. UAP helps splint the client's chest during coughing.
- C. UAP transfers the client to a bedside chair for meals.
- D. UAP lowers the head of the client's bed to 15 degrees
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. In right lower lobe pneumonia, positioning the client with the affected side down helps improve ventilation and drainage.
2. Lowering the head of the bed to 15 degrees promotes pooling of secretions, worsening respiratory status.
3. A, B, and C are appropriate actions that promote client comfort and safety in pneumonia management.
4. Intervening in option D is crucial to prevent complications and promote effective respiratory care.
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The last mammalian structure that air moves through before the alveoli is the
- A. larynx.
- B. glottis.
- C. bronchioles.
- D. trachea.
Correct Answer: C
Rationale: The correct answer is C: bronchioles. After air passes through the trachea, it enters the bronchi, which further divide into bronchioles. The bronchioles are the last structures where air passes before reaching the alveoli for gas exchange. The larynx is involved in sound production and the glottis is the opening between the vocal cords in the larynx. While the trachea is the initial passage for air into the respiratory system, the bronchioles are the final branching structures where air reaches the alveoli, making them the correct answer.
Which vital sign should she immediately report to you—the RN?
- A. Heart rate 98 per minute
- B. Respiratory rate 24 per minute
- C. Blood pressure 168/90
- D. Tympanic temperature 101.4°F
Correct Answer: D
Rationale: The correct answer is D. A temperature of 101.4°F indicates possible infection or complication and requires immediate attention. Heart rate (A), respiratory rate (B), and blood pressure (C) are within acceptable ranges post-suctioning.
Which of these factors does not affect hemoglobin's affinity for oxygen?
- A. RBC metabolic activity
- B. temperature
- C. electrolyte balance
- D. the PO2 of blood
Correct Answer: C
Rationale: The correct answer is C: electrolyte balance. Hemoglobin's affinity for oxygen is primarily influenced by factors such as pH, temperature, and the partial pressure of oxygen (PO2). Electrolyte balance, on the other hand, does not directly impact hemoglobin's ability to bind with oxygen. Changes in electrolyte levels may affect overall blood composition but do not directly alter hemoglobin's oxygen-binding capacity. Therefore, electrolyte balance does not affect hemoglobin's affinity for oxygen, making it the correct choice. RBC metabolic activity can impact oxygen release from hemoglobin, temperature can affect hemoglobin's oxygen-binding capacity, and the PO2 of blood directly influences oxygen binding to hemoglobin.
Which of the following is a risk factor for developing heart failure?
- A. Regular exercise
- B. Low blood cholesterol levels
- C. Smoking
- D. Adequate sleep
Correct Answer: C
Rationale: The correct answer is C: Smoking. Smoking is a risk factor for developing heart failure because it damages the blood vessels, increases blood pressure, and reduces oxygen delivery to the heart. Regular exercise (A) is actually beneficial for heart health. Low blood cholesterol levels (B) are generally considered a positive factor for heart health. Adequate sleep (D) is important for overall well-being but is not a direct risk factor for heart failure. In conclusion, smoking (C) stands out as the correct answer due to its harmful effects on the cardiovascular system.
The nurse is developing a teaching plan for a 64-year-old client with coronary artery disease (CAD). Which factor should the nurse focus on during the teaching session?
- A. Family history of coronary artery disease
- B. Elevated low-density lipoprotein (LDL) level
- C. Greater risk associated with the patient's gender
- D. Increased risk of cardiovascular disease with aging
Correct Answer: B
Rationale: The correct answer is B: Elevated low-density lipoprotein (LDL) level. This is the most relevant factor to focus on during the teaching session for a client with CAD. Elevated LDL levels are a major risk factor for the development and progression of CAD. By addressing this factor, the nurse can educate the client on the importance of managing cholesterol levels through diet, exercise, and medication.
Incorrect choices:
A: Family history of CAD - While family history is a risk factor, it cannot be modified through education alone.
C: Greater risk associated with the patient's gender - Gender is a non-modifiable risk factor and not the primary focus for teaching.
D: Increased risk of cardiovascular disease with aging - While age is a risk factor, the focus should be on modifiable risk factors like LDL levels.