Nokea
What is the purpose of pursed lip breathing?
- A. Helps exhale less volume of air during expiration
- B. Increases expiration
- C. Promotes effective use of the diaphragm
- D. Relieves compensatory burden on upper thorax
Correct Answer: A
Rationale: The correct answer is A because pursed lip breathing helps to slow down and control the exhalation process, allowing the individual to exhale a smaller volume of air with more force. This helps to prevent air trapping in the lungs, improve oxygen exchange, and reduce shortness of breath.
B: Incorrect - Pursed lip breathing does not increase expiration but rather controls it.
C: Incorrect - While pursed lip breathing can promote deep breathing and better oxygen exchange, its primary purpose is to regulate exhalation volume.
D: Incorrect - Pursed lip breathing does not specifically target the upper thorax but rather facilitates a more efficient breathing pattern by reducing air trapping in the lungs.
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Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
- A. "I think you should ask the doctor. Would you like me to cail him for you?"
- B. " The blood supply to the brain has decreased causing permanent brain damage."
- C. "It Is a temporary interruption in the blood flow to the brain."
- D. "TIA means a transient ischemic attack."
Correct Answer: C
Rationale: The correct answer is C: "It is a temporary interruption in the blood flow to the brain." This response is correct because it accurately describes a transient ischemic attack (TIA) as a temporary condition where blood flow to the brain is briefly interrupted. This explanation is clear, concise, and provides the family member with an accurate understanding of TIA.
Choice A is incorrect because it deflects the question and suggests involving the doctor unnecessarily. Choice B is incorrect as it inaccurately states that TIA causes permanent brain damage, which is not true. Choice D is incorrect as it simply defines the acronym without providing any meaningful information about what TIA actually is.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale:
1. Asking about chief concerns helps to focus the interview on the patient's needs.
2. It demonstrates active listening and empathy.
3. Allows the nurse to prioritize issues and provide appropriate care.
4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.
Through which of the following does lymph return to the blood?
- A. Carotid arteries
- B. Inferior vena cava
- C. Aorta
- D. Subclavian veins
Correct Answer: D
Rationale: The correct answer is D: Subclavian veins. Lymph returns to the blood through the subclavian veins because they receive lymphatic drainage from the thoracic duct and right lymphatic duct. Lymphatic vessels merge into lymphatic ducts, which empty into the subclavian veins, allowing lymph to re-enter the bloodstream. The carotid arteries (A) carry oxygen-rich blood to the brain, the aorta (C) is the main artery of the body carrying oxygenated blood from the heart, and the inferior vena cava (B) returns deoxygenated blood from the lower body to the heart. Therefore, choices A, B, and C are incorrect as they are not involved in the return of lymph to the blood.
A patient asks the nurse what side effects to expect from a muscle relaxant medication that has been prescribed. Which of the ff. side effects should the nurse relate?
- A. Hypoglycaemia
- B. Drowsiness
- C. Hypotension
- D. Dyspnea
Correct Answer: B
Rationale: The correct answer is B: Drowsiness. Muscle relaxants can cause drowsiness as a common side effect due to their sedative properties. This can impair alertness and coordination, so it's crucial for the patient to be aware of this potential effect. Choice A, hypoglycemia, is not typically associated with muscle relaxants. Choice C, hypotension, is more commonly linked to medications like antihypertensives. Choice D, dyspnea, which is difficulty breathing, is not a common side effect of muscle relaxants. Therefore, the nurse should primarily focus on educating the patient about the potential side effect of drowsiness.
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
- A. Measure the client’s oral temperature.
- B. Ask a colleague for assistance.
- C. Give the client a clean gown and warm blankets.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: The correct answer is A: Measure the client’s oral temperature. This is the best follow-up because it directly assesses the client's body temperature, providing objective data to confirm the presence of fever. It is essential to gather accurate information to guide appropriate interventions. Asking a colleague for assistance (B) may not address the immediate need for temperature assessment. Giving the client a clean gown and warm blankets (C) may provide comfort but does not address the need for temperature measurement. Obtaining an order for blood cultures (D) is not the initial priority when the client is showing signs of fever; temperature measurement is the first step in assessing the client's condition.