Nokea
Which action should the nurse take first when a client develops epistaxis?
- A. Pack the affected nostril tightly with an epistaxis balloon.
- B. Apply squeezing pressure to the nostrils for 10 minutes.
- C. Obtain silver nitrate that may be needed for cauterization.
- D. Instill a vasoconstrictor medication into the affected nostril.
Correct Answer: B
Rationale: The correct action is to apply squeezing pressure to the nostrils for 10 minutes. This helps control the bleeding by promoting clot formation. It is the initial intervention to stop the bleeding before considering other options. Packing the nostril with a balloon (Choice A) may worsen the bleeding. Obtaining silver nitrate (Choice C) for cauterization is not the first-line approach. Instilling vasoconstrictor medication (Choice D) should be considered after applying pressure if bleeding persists.
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A hospital nurse is participating in a drill during which many "clients" with inhalation anthrax are being admitted. The nurse would anticipate administering the following EXCEPT?
- A. Vancomycin
- B. Ciprofloxacin
- C. Doxycycline
- D. Ethambutol
Correct Answer: D
Rationale: The correct answer is D: Ethambutol. Ethambutol is not used in the treatment of inhalation anthrax. The treatment of choice for inhalation anthrax is a combination of antibiotics such as ciprofloxacin, doxycycline, and sometimes vancomycin. Ethambutol is primarily used in the treatment of tuberculosis, not anthrax. It is important for the nurse to be knowledgeable about the appropriate medications for specific conditions to provide effective care.
Which of the following processes does atmospheric pressure play a role in?
- A. pulmonary ventilation
- B. production of pulmonary surfactant
- C. resistance
- D. surface tension
Correct Answer: A
Rationale: The correct answer is A: pulmonary ventilation. Atmospheric pressure plays a crucial role in pulmonary ventilation by creating a pressure gradient that allows air to flow into and out of the lungs during inhalation and exhalation. When the atmospheric pressure is higher than the pressure inside the lungs, air moves in (inhalation); when the pressure inside the lungs is higher, air moves out (exhalation).
Summary of why the other choices are incorrect:
B: Production of pulmonary surfactant is not directly influenced by atmospheric pressure. Pulmonary surfactant reduces surface tension in the alveoli to prevent collapse.
C: Resistance in the respiratory system is mainly influenced by airway diameter and elasticity of the lungs, not atmospheric pressure.
D: Surface tension in the alveoli is affected by pulmonary surfactant, not atmospheric pressure.
What instructions will you give the nursing assistant who will assist the client with ADLs? (Choose all that apply.)
- A. Use a lift sheet when moving and positioning the client in bed.
- B. Use an electric razor when shaving the client each day.
- C. Use a soft-bristled toothbrush or tooth sponge for oral care.
- D. Use a rectal thermometer to attain a more accurate body temperature.
Correct Answer: D
Rationale: The correct answer includes A, B, and C. Using a lift sheet (A), electric razor (B), and soft-bristled toothbrush (C) are safe practices during anticoagulation therapy. Using a rectal thermometer (D) is contraindicated due to bleeding risk.
Foetal hemoglobin has a Sigmoid dissociation curve which is shifted to left relative to adult Hb because
- A. Foetal Hb has higher P50
- B. Foetal HB has lower P50 (18-20 mm Hg) than Adult Hb (26.6 mm.Hg)
- C. Foetal Hb readily accept Oxygen
- D. Foetal Hb easily remove Carbon dioxide
Correct Answer: B
Rationale: The correct answer is B because foetal Hb has a lower P50 (18-20 mm Hg) than adult Hb (26.6 mm Hg). A lower P50 indicates higher oxygen affinity, allowing foetal Hb to bind oxygen more readily at lower partial pressures. This shift to the left of the dissociation curve ensures efficient oxygen transfer from the maternal bloodstream to the foetus. Choices A, C, and D are incorrect because foetal Hb having a higher P50 (A), readily accepting oxygen (C), or easily removing carbon dioxide (D) would not explain the left shift in the dissociation curve.
The patient with sleep apnea is fitted with a continuous positive airway pressure (CPAP) mask and asks the nurse how this device will help. How should the nurse respond?
- A. The device delivers constant positive pressure to keep your airway open.
- B. The device will require you to be intubated to open your airway.
- C. The device delivers oxygen only when you are apneic.
- D. The device delivers negative pressure to stimulate your respirations.
Correct Answer: A
Rationale: The correct answer is A because a CPAP mask delivers a constant positive pressure to keep the airway open during sleep, preventing airway collapse and interruptions in breathing. This helps improve oxygenation and reduce the frequency of apnea episodes. Choice B is incorrect as intubation is not required with CPAP. Choice C is incorrect as CPAP does not deliver oxygen, it only provides pressurized air. Choice D is incorrect as CPAP delivers positive pressure, not negative pressure, to support breathing.