Nokea
What causes an audible wheeze in Mr. Ross’ right lung?
- A. Inflammation of pleural surfaces
- B. Obstruction of the bronchus
- C. Collection of exudate in the pleural cavity
- D. Dilatation of the alveoli
Correct Answer: B
Rationale: Bronchial obstruction leads to turbulent airflow, producing wheezing.
You may also like to solve these questions
What nursing measure assumes priority for Mr. Johnson with sudden diarrhea and high fever?
- A. Determine if he had been working on an air-conditioning unit of a high-rise building
- B. Place the patient in isolation
- C. Monitor respiratory status carefully and observe for signs of hypoxia
- D. Begin discharge teaching
Correct Answer: C
Rationale: The correct answer is C, to monitor respiratory status and observe for signs of hypoxia. This is because sudden diarrhea and high fever can indicate a potential infectious illness, which can lead to respiratory complications such as pneumonia. Monitoring respiratory status is crucial to detect any signs of respiratory distress or hypoxia early on.
A: Determining his work on an air-conditioning unit is not a priority at this time as it does not directly address his immediate health concerns.
B: Placing the patient in isolation may be necessary later depending on the diagnosis, but it is not the priority at this moment.
D: Beginning discharge teaching is not appropriate as the patient is currently experiencing acute symptoms that require immediate attention.
In summary, monitoring respiratory status is the priority to ensure early detection and intervention for any potential respiratory complications in a patient with sudden diarrhea and high fever.
For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.
A 20-year-old patient with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support?
- A. Irreversible cessation of all brain functions.
- B. Absence of brainstem reflexes.
- C. No spontaneous respirations.
- D. Fear of pain
Correct Answer: B
Rationale: Brain death is confirmed when there is irreversible cessation of all brain functions, absence of brainstem reflexes, and no spontaneous respirations, meeting legal and medical criteria for death.
To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?
- A. Encourage deep breathing
- B. Elevate the head of the bed
- C. Administer oxygen per mask
- D. Position the patient in a side-lying position
Correct Answer: D
Rationale: Side-lying position prevents tongue obstruction and facilitates drainage of secretions.
Donna is a healthy, 46-year-old woman scheduled for elective surgery next week. You would include in her preoperative preparation
- A. A pulmonary function test and chest x-ray.
- B. A complete blood count (CBC), chemistry panel, and pregnancy test.
- C. Urine culture, thyroid panel, and cortisol level.
- D. Glucose tolerance test, ankle-brachial index, and electrocardiogram (EKG).
Correct Answer: B
Rationale: Basic lab tests ensure the patient is fit for surgery.