Nokea
What instructions will you give the nursing assistant who will assist the client with ADLs? (Choose all that apply.)
- A. Use a lift sheet when moving and positioning the client in bed.
- B. Use an electric razor when shaving the client each day.
- C. Use a soft-bristled toothbrush or tooth sponge for oral care.
- D. Use a rectal thermometer to attain a more accurate body temperature.
Correct Answer: D
Rationale: The correct answer includes A, B, and C. Using a lift sheet (A), electric razor (B), and soft-bristled toothbrush (C) are safe practices during anticoagulation therapy. Using a rectal thermometer (D) is contraindicated due to bleeding risk.
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The organ of the respiratory system that closes when food is being swallowed is the:
- A. nose
- B. pharynx
- C. larynx
- D. trachea
Correct Answer: C
Rationale: The correct answer is C: larynx. The larynx houses the vocal cords and serves as a passageway for air between the pharynx and trachea. During swallowing, the larynx closes to prevent food and liquids from entering the airway, directing them towards the esophagus instead. The nose (A) is not directly involved in swallowing. The pharynx (B) is a shared pathway for both air and food, but it does not actively close during swallowing. The trachea (D) is responsible for transporting air to and from the lungs and does not play a role in swallowing.
Which of the following would be the most appropriate nursing intervention when caring for a client with a fractured rib?
- A. Apply immobilization device after examination by physician
- B. Discourage taking deep breaths if breathing is painful
- C. Advice against using analgesics and regional nerve blocks
- D. Encourage increased fluid intake if pulmonary contusion exists
Correct Answer: A
Rationale: The correct answer is A. Applying an immobilization device after physician evaluation helps stabilize the rib and reduce pain. B (discouraging deep breaths) is harmful as it can lead to atelectasis. C (advising against analgesics) is incorrect because pain management is essential. D (increasing fluid intake) is secondary and depends on the presence of pulmonary complications.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on which finding?
- A. SpO of 86%
- B. Crackles in both lower lobes
- C. Temperature of 101.4ºF (38.6ºC)
- D. Production of greenish purulent sputum
Correct Answer: A
Rationale: Impaired gas exchange is indicated by a low SpO2 level, in this case 86%, which suggests inadequate oxygenation. Crackles, temperature, and sputum production are important assessments but do not directly indicate impaired gas exchange.
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.
The ________ inhibit the apneustic centers and promote passive or active exhalation.
- A. DRG
- B. VRG
- C. pneumotaxic centers
- D. LRG
Correct Answer: C
Rationale: The correct answer is C: pneumotaxic centers. The pneumotaxic centers are located in the pons and regulate the rate and depth of breathing by inhibiting the apneustic centers in the medulla. This inhibition helps to promote passive or active exhalation.
A: DRG (dorsal respiratory group) is responsible for the initiation of inspiration.
B: VRG (ventral respiratory group) is involved in both inspiration and expiration.
D: LRG is not a recognized respiratory center in the brainstem.
In summary, the pneumotaxic centers play a crucial role in regulating breathing by inhibiting the apneustic centers, leading to exhalation.