Nokea
The nursing assistant tells you that the client on oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the client's comfort for this problem?
- A. Suggest that the client's oxygen be humidified.
- B. Suggest that the client be placed on a simple face mask.
- C. Suggest that the client be provided an extra pillow.
- D. Suggest that the client sit up in a chair at the bedside.
Correct Answer: A
Rationale: The correct answer is A. Humidifying oxygen reduces nasal dryness and irritation caused by high-flow oxygen through a nasal cannula. Using a face mask (B) might help but is less practical for long-term use. Providing an extra pillow (C) or sitting up in a chair (D) does not address the nasal discomfort directly.
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In general, when looking at acid-base balance, how does the body compensate with metabolic acidosis?
- A. Lungs ""blow off"" CO2 to raise pH
- B. Lungs retain CO2 to lower pH
- C. Kidneys retain more HCO3 to raise the pH
- D. Kidneys excrete more HCO3 to lower pH
Correct Answer: A
Rationale: The correct answer is A. In metabolic acidosis, the lungs compensate by increasing respiratory rate and depth ('blowing off' CO2) to reduce acidity and raise pH. B is incorrect because retaining CO2 would worsen acidosis. C is partially true long-term but slower acting than pulmonary compensation. D is incorrect because excreting bicarbonate lowers pH further.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
- A. The client rates pain as a 5/10 at the site of the procedure.
- B. A small amount of drainage from the site is noted.
- C. Pulse oximetry is 93% on 2 liters of oxygen.
- D. The trachea is deviated toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because tracheal deviation indicates a potential pneumothorax, a life-threatening complication of thoracentesis. Trachea should be midline. A, B, and C are incorrect because mild pain, small drainage, and slightly decreased oxygen saturation are expected findings post-thoracentesis and do not necessitate immediate action.
In pleurisy,
- A. some of the alveoli fill with fluid.
- B. the pleural membrane becomes inflamed and swollen and causes painful breathing.
- C. the diaphragm develops muscular cramps.
- D. the vagus nerve is irritated
Correct Answer: B
Rationale: The correct answer is B because pleurisy is inflammation of the pleural membrane, causing pain during breathing due to friction between the inflamed layers. Choice A is incorrect as alveoli are not directly affected in pleurisy. Choice C is incorrect as pleurisy does not cause cramps in the diaphragm. Choice D is incorrect as the vagus nerve irritation is not a characteristic feature of pleurisy.
During inspiration
- A. diaphragm relaxes and thoracic space decrease
- B. diaphragm contract only
- C. Diaphragm contract and thoracic space increase
- D. both A and D
Correct Answer: C
Rationale: During inspiration, the diaphragm contracts, causing it to move downward and increase the thoracic space. This creates a negative pressure in the lungs, allowing air to rush in. Choice A is incorrect as the diaphragm contracts rather than relaxes during inspiration. Choice B is incorrect since other muscles like the external intercostals also aid in expanding the thoracic cavity. Choice D is incorrect because it combines a correct statement with an incorrect one. Therefore, the correct answer is C as it accurately describes the process of inspiration involving both diaphragm contraction and an increase in thoracic space.
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?
- A. Sputum production
- B. Shortness of breath
- C. Throat discomfort
- D. Epistaxis
Correct Answer: B
Rationale: The correct answer is B: Shortness of breath. Following a thoracoscopic procedure for a pleural effusion, shortness of breath is a priority assessment as it could indicate complications such as pneumothorax or respiratory distress. Sputum production (A) may be important but is secondary to respiratory distress. Throat discomfort (C) and epistaxis (D) are not directly related to the procedure or potential complications and would not be the priority assessment in this scenario.