Nokea
The patient with sleep apnea is fitted with a continuous positive airway pressure (CPAP) mask and asks the nurse how this device will help. How should the nurse respond?
- A. The device delivers constant positive pressure to keep your airway open.
- B. The device will require you to be intubated to open your airway.
- C. The device delivers oxygen only when you are apneic.
- D. The device delivers negative pressure to stimulate your respirations.
Correct Answer: A
Rationale: The correct answer is A because a CPAP mask delivers a constant positive pressure to keep the airway open during sleep, preventing airway collapse and interruptions in breathing. This helps improve oxygenation and reduce the frequency of apnea episodes. Choice B is incorrect as intubation is not required with CPAP. Choice C is incorrect as CPAP does not deliver oxygen, it only provides pressurized air. Choice D is incorrect as CPAP delivers positive pressure, not negative pressure, to support breathing.
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Which action should the nurse take first when a client develops epistaxis?
- A. Pack the affected nostril tightly with an epistaxis balloon.
- B. Apply squeezing pressure to the nostrils for 10 minutes.
- C. Obtain silver nitrate that may be needed for cauterization.
- D. Instill a vasoconstrictor medication into the affected nostril.
Correct Answer: B
Rationale: The correct action is to apply squeezing pressure to the nostrils for 10 minutes. This helps control the bleeding by promoting clot formation. It is the initial intervention to stop the bleeding before considering other options. Packing the nostril with a balloon (Choice A) may worsen the bleeding. Obtaining silver nitrate (Choice C) for cauterization is not the first-line approach. Instilling vasoconstrictor medication (Choice D) should be considered after applying pressure if bleeding persists.
A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
- A. 14%
- B. 21%
- C. 28%
- D. 31%
Correct Answer: B
Rationale: The correct answer is B (21%). Room air contains approximately 21% oxygen. By removing the supplemental oxygen, the client is now breathing the oxygen content present in the surrounding air. Choices A, C, and D are incorrect as they do not reflect the standard oxygen concentration in room air. Oxygen concentration in room air is typically around 21%, making choice B the most accurate option.
A hospital nurse is participating in a drill during which many "clients" with inhalation anthrax are being admitted. The nurse would anticipate administering the following EXCEPT?
- A. Vancomycin
- B. Ciprofloxacin
- C. Doxycycline
- D. Ethambutol
Correct Answer: D
Rationale: The correct answer is D: Ethambutol. Ethambutol is not used in the treatment of inhalation anthrax. The treatment of choice for inhalation anthrax is a combination of antibiotics such as ciprofloxacin, doxycycline, and sometimes vancomycin. Ethambutol is primarily used in the treatment of tuberculosis, not anthrax. It is important for the nurse to be knowledgeable about the appropriate medications for specific conditions to provide effective care.
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 78-yr-old patient with newly diagnosed hypertension?
- A. 98/56 mm Hg
- B. 118/76 mm Hg
- C. 128/92 mm Hg
- D. 142/78 mm Hg
Correct Answer: B
Rationale: The correct answer is B (118/76 mm Hg) because it falls within the recommended range for a 78-year-old patient with hypertension. The systolic BP should ideally be below 140 mm Hg and the diastolic BP below 90 mm Hg for this age group. Option A is too low for systolic BP, indicating hypotension. Option C has elevated diastolic BP, suggesting uncontrolled hypertension. Option D has high systolic BP, indicating a need for therapy adjustment. Thus, only option B aligns with the guidelines, making it the correct choice.
Food and drink are prevented from entering the respiratory passageways during swallowing by means of the
- A. glottis.
- B. pharynx.
- C. epiglottis.
- D. larynx.
Correct Answer: C
Rationale: The correct answer is C: epiglottis. During swallowing, the epiglottis covers the opening of the larynx to prevent food and drink from entering the respiratory passageways. It acts as a lid that directs food and liquids to the esophagus instead of the trachea. The glottis (choice A) is the space between the vocal cords, the pharynx (choice B) is the passageway for food and air, and the larynx (choice D) contains the vocal cords. The epiglottis specifically functions to protect the airway during swallowing.