Nokea
When caring for a patient with acquired immune deficiency syndrome (AIDS)
- A. the nurse is aware that this patient is most at risk for developing which type of pneumonia?
- B. Hypostatic
- C. Streptococcus pneumoniae
- D. Atypical
Correct Answer: D
Rationale: The correct answer is D: Atypical pneumonia. Patients with AIDS are most susceptible to atypical pneumonia caused by organisms like Pneumocystis jiroveci. This is due to their weakened immune system. Hypostatic pneumonia is typically seen in bedridden patients, not specific to AIDS. Streptococcus pneumoniae is a common cause of community-acquired pneumonia but not particularly associated with AIDS. Therefore, the correct choice is D, as it aligns with the specific risk profile of AIDS patients for atypical pneumonia.
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During inspiration, air passes into lungs due to
- A. Increase in volume of thoracic cavity and fall in lung pressure
- B. Fall in pressure inside the lungs
- C. Increased volume of thoracic cavity
- D. Muscular expansion of lungs
Correct Answer: A
Rationale: Correct Answer: A - Increase in volume of thoracic cavity and fall in lung pressure
Rationale:
1. During inspiration, the diaphragm contracts and moves downward, increasing the volume of the thoracic cavity.
2. The external intercostal muscles also contract, lifting the ribcage and further expanding the thoracic cavity.
3. As thoracic cavity volume increases, lung pressure decreases, creating a pressure gradient that allows air to flow into the lungs.
Summary:
B: Fall in pressure inside the lungs - This is a consequence of the increase in thoracic cavity volume, not the cause of air entering the lungs.
C: Increased volume of thoracic cavity - This is correct but does not explain how air enters the lungs.
D: Muscular expansion of lungs - Lungs do not expand on their own; it is the thoracic cavity that expands to create the pressure gradient for air entry.
For a male client with an endotracheal (ET) tube, which nursing action is most essential?
- A. Auscultating the lungs for bilateral breath sounds.
- B. Turning the client from side to side every 2 hours.
- C. Monitoring serial blood gas values every 4 hours.
- D. Providing frequent oral hygiene.
Correct Answer: A
Rationale: The correct answer is A: Auscultating the lungs for bilateral breath sounds. This is the most essential nursing action for a male client with an endotracheal tube because it ensures proper placement of the tube and adequate ventilation. By auscultating the lungs, the nurse can assess for any potential complications such as tube displacement, pneumothorax, or mucus plugging. This action helps in early detection of respiratory issues and prompt intervention if needed.
Summary:
- Choice B (Turning the client from side to side every 2 hours) is important for preventing pressure ulcers but not as critical as assessing breath sounds.
- Choice C (Monitoring serial blood gas values every 4 hours) is important for evaluating respiratory status but does not provide immediate information on tube placement.
- Choice D (Providing frequent oral hygiene) is important for preventing infections but does not directly assess the client's respiratory status with an ET tube.
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60 pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?
- A. Tell the client that he needs to quit smoking to stop further cancer development.
- B. Encourage the client to be completely honest about both tobacco and marijuana use.
- C. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
- D. Avoid giving the client false hope regarding cancer treatment and prognosis.
Correct Answer: C
Rationale: Rationale:
C is correct as maintaining a nonjudgmental attitude is crucial to establish trust and rapport with the client. It helps the client feel comfortable sharing information, leading to better assessment and care. A is incorrect as quitting smoking may not be the immediate priority. B is incorrect as honesty about marijuana use is not the primary concern. D is incorrect as it does not address the importance of establishing a therapeutic relationship.
Each of the following is true regarding the spleen, except:
- A. Spleen is located posterolateral to the stomach, and contacts the diaphragm and left kidney.
- B. Splenic veins, arteries, and lymphatic vessels communicate with the spleen at the hilum.
- C. The spleen is a primary lymphoid organ, serving to filter lymph fluid.
- D. Lymphocytes and dendritic cells are concentrated in the white pulp.
Correct Answer: C
Rationale: Rationale:
C is correct because the spleen is a secondary lymphoid organ, not a primary one. The spleen filters blood, not lymph fluid.
A is correct as the spleen is located in the described position.
B is correct as the splenic vessels do communicate with the spleen at the hilum.
D is correct as lymphocytes and dendritic cells are indeed concentrated in the white pulp.
Summary:
A, B, and D are correct statements about the spleen. C is incorrect because the spleen is a secondary lymphoid organ, not a primary one.
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?
- A. Assess the client's pain level.
- B. Keep the client's head elevated.
- C. Teach the client about the causes of nasal bleeding.
- D. Assess the client's airway.
Correct Answer: D
Rationale: The correct answer is D: Assess the client's airway. This is the priority action as airway patency is always the top priority in any emergency situation. In this case, posterior nasal bleeding can lead to blood flow into the throat, potentially obstructing the airway. Ensuring the client's airway is clear and maintaining adequate oxygenation is crucial for their safety.
Choice A (Assess the client's pain level) is not the priority when there is a potential risk to the airway. Choice B (Keep the client's head elevated) may be done after confirming airway patency. Choice C (Teach the client about the causes of nasal bleeding) is important but not the immediate priority in this situation.