Nokea
When you swallow, the epiglottis covers the opening to the
- A. pharynx.
- B. esophagus.
- C. larynx.
- D. bronchus.
Correct Answer: C
Rationale: The correct answer is C: larynx. When you swallow, the epiglottis covers the opening to the larynx to prevent food or liquid from entering the airway and instead directs it towards the esophagus. The epiglottis acts as a protective mechanism to ensure that food goes down the correct pathway. Choices A (pharynx), B (esophagus), and D (bronchus) are incorrect because the epiglottis does not directly cover the opening to these structures during swallowing. The epiglottis specifically functions to protect the larynx and the airway during the swallowing process.
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To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient?
- A. Dull percussion sounds on the injured side
- B. Severe respiratory distress and tracheal deviation
- C. Muffled and distant heart sounds with decreasing blood pressure
- D. Decreased movement and diminished breath sounds on the affected side
Correct Answer: B
Rationale: In a tension pneumothorax, there is a buildup of air under pressure in the pleural space, leading to severe respiratory distress and tracheal deviation. This can be a life-threatening emergency that requires immediate intervention.
You are evaluating and assessing a client diagnosed with chronic emphysema. The client is on oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
- A. The client has fine bibasilar crackles.
- B. The client's respiratory rate is 8 breaths/minute.
- C. The client sits up and leans over the nightstand.
- D. The client has a large barrel chest.
Correct Answer: B
Rationale: The correct answer is B. A respiratory rate of 8 breaths/minute is abnormally low and indicates potential hypoventilation or respiratory depression, which is concerning in a client with chronic emphysema. Fine crackles (A) and barrel chest (D) are common findings but not immediately alarming. Sitting up and leaning forward (C) is a compensatory mechanism for easier breathing.
Which statement made by a client with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?
- A. I enjoy eating 1/4 cup of walnuts every day.
- B. I will switch from whole milk to skim milk.
- C. I can have a glass of wine with dinner every night.
- D. I like red meat and I will plan to eat it more often.
Correct Answer: D
Rationale: The correct answer is D because red meat is high in saturated fat which can worsen coronary artery disease. Eating it more often contradicts the TLC diet's aim to reduce saturated fat intake. Choice A is correct as walnuts are heart-healthy. Choice B is correct as switching to skim milk reduces saturated fat. Choice C is incorrect as alcohol should be consumed in moderation, not daily.
Which of the following neurological controls of ventilation responds to changes in the pH and levels of oxygen and CO2 in the blood?
- A. Central chemoreceptors in the medulla
- B. Peripheral chemoreceptors in the aortic arch and carotid arteries
- C. Respiratory centers in the medulla oblongata and pons
- D. Central chemoreceptors in the spinal cord
Correct Answer: A
Rationale: The correct answer is A. Central chemoreceptors in the medulla are highly sensitive to changes in pH and CO2 levels, influencing respiratory rate and depth. B is incorrect because peripheral chemoreceptors respond mainly to O2 levels. C refers to general respiratory control centers, not specific chemoreceptor function. D is incorrect as the spinal cord lacks central chemoreceptors.
The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse's postprocedure care?
- A. Assisting with pulmonary function testing (PFT)
- B. Maintaining the patient's chest tube
- C. Administering oral suction as needed
- D. Performing chest physiotherapy
Correct Answer: B
Rationale: The correct answer is B: Maintaining the patient's chest tube. After a mediastinotomy, the focus of postprocedure care is to ensure proper drainage and prevent pneumothorax. Chest tube maintenance is crucial for monitoring drainage, preventing complications, and promoting lung expansion. Assisting with PFT (A) is not a priority immediately post mediastinotomy. Administering oral suction (C) can disrupt the chest tube and increase infection risk. Performing chest physiotherapy (D) may be indicated later but is not the immediate priority.