Nokea
To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient?
- A. Dull percussion sounds on the injured side
- B. Severe respiratory distress and tracheal deviation
- C. Muffled and distant heart sounds with decreasing blood pressure
- D. Decreased movement and diminished breath sounds on the affected side
Correct Answer: B
Rationale: In a tension pneumothorax, there is a buildup of air under pressure in the pleural space, leading to severe respiratory distress and tracheal deviation. This can be a life-threatening emergency that requires immediate intervention.
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The nurse is aware that the characteristic of emphysema that gives rise to the "Pink Puffer" label is the emphysemic patient's:
- A. Dyspnea.
- B. Barrel chest.
- C. Thin body.
- D. Normal ABGs.
Correct Answer: D
Rationale: The correct answer is D: Normal ABGs. In emphysema, the destruction of alveoli leads to impaired gas exchange, causing respiratory acidosis and hypoxemia. However, "Pink Puffers" maintain normal or slightly low CO2 levels (normal ABGs) due to persistent hyperventilation. This compensatory mechanism helps them maintain adequate oxygen levels despite damaged alveoli. Dyspnea (choice A) and barrel chest (choice B) are common in emphysema but do not specifically contribute to the "Pink Puffer" label. Thin body (choice C) is associated with another type of COPD, chronic bronchitis.
Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for:
- A. Patients with an acute asthma attack.
- B. Patients with narcolepsy.
- C. Patients under age
- D. Elderly patients.
Correct Answer: D
Rationale: The correct answer is D: Elderly patients. Ephedrine, a sympathomimetic amine, can exacerbate existing CNS conditions in elderly patients, leading to adverse effects like confusion, agitation, and increased risk of falls. Elderly patients are more sensitive to CNS stimulants due to age-related changes in drug metabolism and clearance, making them more susceptible to negative effects. Choices A, B, and C are incorrect because patients with acute asthma attacks may benefit from ephedrine's bronchodilator effects, patients with narcolepsy may benefit from its stimulant properties, and age alone is not a contraindication for ephedrine use.
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?
- A. Face mask
- B. Venturi mask
- C. Aerosol mask
- D. Tracheostomy collar
Correct Answer: B
Rationale: The correct answer is B: Venturi mask. The Venturi mask delivers a precise oxygen concentration by mixing oxygen with room air through different sized ports, allowing for accurate oxygen delivery. This is important for patients with COPD who require specific oxygen levels to prevent oxygen toxicity or hypoxemia.
A: Face mask delivers a less precise oxygen concentration and may not be suitable for patients who require exact oxygen levels.
C: Aerosol mask is used for delivering medications or humidified air, not for precise oxygen concentration.
D: Tracheostomy collar is used for patients with a tracheostomy and is not typically used for delivering precise oxygen concentration in COPD.
Dead air is not involved in respiration because
- A. It is very low quantity
- B. It is trapped in nasal passage
- C. It contains less Oxygen
- D. It is present deep in the lungs
Correct Answer: D
Rationale: The correct answer is D because dead air is the air present in the alveoli that does not participate in gas exchange. It is located deep in the lungs, beyond the respiratory bronchioles where gas exchange occurs. Dead air does not reach the alveoli to participate in respiration. Choices A, B, and C are incorrect because the quantity of dead air or its oxygen content are not the primary reasons why it is not involved in respiration.
The partial pressure of oxygen in atmospheric air at sea level is
- A. greater than the partial pressure of oxygen in atmospheric air at the top of Mt. Everest
- B. less than the partial pressure of oxygen in atmospheric air at the top of Mt. Everest
- C. equal to the partial pressure of oxygen in atmospheric air at the top of Mt. Everest
- D. equal to the sum of partial pressures from carbon dioxide and nitrogen
Correct Answer: A
Rationale: The correct answer is A because the partial pressure of oxygen decreases with increasing altitude due to the decrease in atmospheric pressure. At sea level, the atmospheric pressure is higher, resulting in a higher partial pressure of oxygen compared to the top of Mt. Everest. Choice B is incorrect because the partial pressure of oxygen is not higher at higher altitudes. Choice C is incorrect because the partial pressure of oxygen is not equal at sea level and Mt. Everest. Choice D is incorrect because the question specifically asks about the partial pressure of oxygen only, not the sum of partial pressures from other gases.