Nokea
When the diaphragm and external intercostals muscles contract, which of the following actions does NOT occur?
- A. air moves into the lung
- B. the intrapleural pressure increases
- C. the diaphragm moves inferiorly
- D. the intrapulmonary pressure decreases
Correct Answer: B
Rationale: When the diaphragm and external intercostals contract, the thoracic cavity expands, causing the lungs to expand and the intrapulmonary pressure to decrease (choice D). This decrease in pressure allows air to flow into the lungs (choice A). The diaphragm moves inferiorly during contraction, not superiorly (choice C). The intrapleural pressure actually decreases when these muscles contract, not increases, due to increased thoracic volume and decreased intrapleural pressure acting as a suction to keep the lungs inflated (choice B). Therefore, the correct answer is B, as the intrapleural pressure actually decreases when the diaphragm and external intercostals contract.
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Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
- A. Inform the physician.
- B. Continue to monitor the client.
- C. Reinforce the occlusive dressing.
- D. Encourage the client to deep breathe.
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. Fluctuation of fluid level in the water seal chamber post chest tube insertion indicates proper functioning of the chest tube system. This signifies that the tube is effectively draining fluid or air from the pleural space. It is essential to continue monitoring the client to ensure ongoing proper functioning of the chest tube. Informing the physician (Choice A) is not necessary at this point unless there are other concerning symptoms. Reinforcing the occlusive dressing (Choice C) is not indicated unless there is a leak or issue with the dressing. Encouraging the client to deep breathe (Choice D) is unrelated to the assessment of the chest tube system.
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?
- A. Document the findings.
- B. Administer oxygen therapy.
- C. Position the client in high-Fowler position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct action is to document the findings first because the harsh hollow sound over the trachea and larynx could indicate a potential issue with the airway or respiratory function. Documenting the findings allows for accurate communication with other healthcare providers and helps track changes in the client's condition. Administering oxygen therapy or albuterol should not be done without further assessment or orders from a healthcare provider. Positioning the client in high-Fowler position may not be the priority until a more thorough assessment is completed.
which of the following is a chronic respiratory disorder caused by smoking?
- A. asthma
- B. emphysema
- C. respiratory alkalosis
- D. Acidosis
Correct Answer: B
Rationale: Emphysema is the correct answer because it is a chronic respiratory disorder specifically caused by smoking. Smoking damages the air sacs in the lungs, leading to shortness of breath and difficulty breathing. Asthma is a separate condition involving airway inflammation. Respiratory alkalosis and acidosis refer to imbalances in blood pH levels, not directly caused by smoking.
The organs of the respiratory zone of the respiratory system include all the following EXCEPT:
- A. trachea
- B. small bronchioles
- C. alveoli ducts
- D. alveoli
Correct Answer: A
Rationale: The correct answer is A: trachea. The trachea is not part of the respiratory zone, which is where gas exchange occurs. The respiratory zone includes the small bronchioles, alveoli ducts, and alveoli. The trachea is part of the conducting zone, which is responsible for transporting air to and from the respiratory zone. Therefore, the trachea is not directly involved in gas exchange, making it the correct answer. The other choices, B: small bronchioles, C: alveoli ducts, and D: alveoli, are all part of the respiratory zone and play a crucial role in gas exchange.
When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report?
- A. Confusion
- B. An abrupt onset of fever and chills
- C. A recent loss of consciousness
- D. A gradual onset of headache and sore throat
Correct Answer: B
Rationale: In patients with Community-Acquired Pneumonia (CAP), an abrupt onset of fever and chills is a common symptom to expect. This is due to the rapid inflammatory response in the lungs. Confusion, loss of consciousness, and gradual headache and sore throat are less likely to be reported initially.