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What is the term used to describe the fluid buildup in the lungs often seen in heart failure patients?
- A. Ascites
- B. Edema
- C. Pleurisy
- D. Effusion
Correct Answer: B
Rationale: The correct answer is B: Edema. In heart failure patients, fluid buildup in the lungs is known as pulmonary edema. This occurs due to the heart's inability to pump effectively, leading to fluid leaking into the lungs' air sacs. Ascites (A) is fluid buildup in the abdomen, not the lungs. Pleurisy (C) is inflammation of the lining around the lungs, not fluid buildup. Effusion (D) refers to fluid accumulation in body cavities like the chest or abdomen, but it is not specific to the lungs like pulmonary edema.
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Which of the following are not present prior to birth?
- A. Pulmonary arterial resistance is high
- B. Pulmonary vessels are collapsed
- C. Rib cage is compressed
- D. Alveoli are expanded
Correct Answer: D
Rationale: The correct answer is D: Alveoli are expanded. Prior to birth, the alveoli in the lungs are collapsed, and they begin to expand and develop after birth when the baby starts breathing air. A: Pulmonary arterial resistance is high due to blood flow bypassing the lungs. B: Pulmonary vessels are collapsed to prevent blood flow in the fetal lungs. C: The rib cage is compressed in the womb due to the limited space, but it expands after birth to allow for lung expansion.
The Pseudostratified ciliated columnar epithelium lining the trachea is composed of
- A. Goblet cells
- B. Macrophages
- C. Fibroblast
- D. All these
Correct Answer: A
Rationale: The correct answer is A: Goblet cells. Goblet cells are responsible for secreting mucus in the respiratory tract, aiding in trapping and removing foreign particles. This is crucial for protecting the lungs from debris and pathogens. Macrophages are immune cells that engulf and digest pathogens, not a component of the epithelium. Fibroblasts are connective tissue cells, not part of the epithelial lining. Therefore, the correct answer is A.
A nurse is assessing clients on a rehabilitation unit. Which client is not at risk for airway loss related to aspirated oral and nasopharyngeal secretions?
- A. A 24 year old with a traumatic brain injury
- B. A 36 year old who fractured his left femur
- C. A 58 year old getting radiation therapy
- D. A 66 year old who is a quadriplegic
Correct Answer: B
Rationale: The correct answer is B, a 36-year-old who fractured his left femur. This client is not at risk for airway loss related to aspirated secretions because a femur fracture does not directly impact the airway or swallowing function. Traumatic brain injury (choice A), radiation therapy (choice C), and quadriplegia (choice D) can all impair the client's ability to protect their airway and increase the risk of aspirating secretions. Therefore, these clients are at higher risk compared to the client with a femur fracture.
Which information from a client helps the nurse confirm the previous diagnosis of chronic stable angina?
- A. The pain wakes me up at night.
- B. The pain is level 3 to 5 (0 to 10 scale).
- C. The pain has gotten worse over the last week.
- D. The pain goes away after I stop jogging.
Correct Answer: D
Rationale: The correct answer is D because chronic stable angina is characterized by chest pain or discomfort that is triggered by physical exertion or emotional stress and relieved by rest or medication. Therefore, the fact that the pain goes away after stopping jogging aligns with the typical pattern of chronic stable angina.
A: The pain waking the client up at night is more indicative of unstable angina or a heart attack.
B: The level of pain on a scale does not provide conclusive evidence of chronic stable angina.
C: Pain worsening over time may suggest unstable angina or a heart attack rather than chronic stable angina.
A nurse is providing care after auscultating a client's breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: The correct answer is C because wheezes indicate narrowing of airways, requiring bronchodilation. Step 1: Identify the assessment finding (wheezes). Step 2: Understand that wheezes indicate airway constriction. Step 3: Appropriately intervene by administering a bronchodilator to dilate the airways and improve breathing. Other choices are incorrect because: A: Increasing oxygen flow rate does not address airway constriction. B: Encouraging coughing for crackles does not address airway narrowing. D: Deep breathing for vesicular sounds does not target airway constriction.