Nokea
Which action should you take next?
- A. Reassure the client that the ventilator will do the work of breathing for her.
- B. Manually ventilate the client while you assess possible reasons for the high pressure alarm.
- C. Increase the FiO2 on the ventilator to 100% in preparation for endotracheal suctioning.
- D. Insert an oral airway to prevent the client from biting on the endotracheal tube.
Correct Answer: B
Rationale: The correct answer is B. High pressure alarms and desaturation require immediate manual ventilation and assessment for causes. Reassurance (A) is insufficient. Increasing FiO2 (C) and inserting an oral airway (D) are secondary actions.
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When examining the posterior pharynx and tonsils, which of the following objective data does the nurse note?
- A. Difficulty in sneezing
- B. Suppressed gag reflex
- C. Deformities
- D. Inflammation
Correct Answer: D
Rationale: The correct answer is D. Inflammation is a key finding during examination of the posterior pharynx and tonsils, especially in infections such as tonsillitis. A (difficulty in sneezing) is unrelated to pharyngeal assessment. B (suppressed gag reflex) might indicate neurological issues but isn't typically noted during routine exams. C (deformities) is rare unless there's structural abnormality.
Phrenic nerve are
- A. in diaphragmatic area
- B. at c3 to c5
- C. Both A and B
- D. non
Correct Answer: C
Rationale: The phrenic nerve innervates the diaphragm and arises from cervical nerve roots C3 to C5. Choice C is correct as it accurately states that the phrenic nerve is located in the diaphragmatic area and originates from C3 to C5. Choice A is incorrect as it only mentions the diaphragmatic area without specifying the cervical levels. Choice B is incorrect as it only mentions the cervical levels without specifying the diaphragmatic area. Choice D is incorrect as the phrenic nerve does exist.
A nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. The primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What action by the nurse is best?
- A. Teach the client about possible drowsiness.
- B. Instruct the client to drink plenty of water.
- C. Consult with the PHCP about the medication.
- D. Encourage the client to take the medication with food.
Correct Answer: C
Rationale: The correct answer is C: Consult with the PHCP about the medication. This is the best action because diphenhydramine may not be the most appropriate medication for older adults due to potential side effects like increased risk of falls, confusion, and urinary retention. Consulting with the PHCP will ensure that the medication is safe and effective for the client.
A: Teaching about drowsiness is important but not the priority.
B: Drinking water is generally good advice but not specific to diphenhydramine.
D: Taking medication with food can help reduce stomach upset but doesn't address the concerns related to diphenhydramine in older adults.
Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:
- A. Dyspnea
- B. Chest pain
- C. A bloody, productive cough.
- D. Bronchoscopy
Correct Answer: B
Rationale: The correct answer is B: Chest pain. Chest pain can be one of the first symptoms of tuberculosis due to inflammation of the lung tissue or pleura. Dyspnea (A) typically occurs in later stages as the disease progresses. A bloody, productive cough (C) is a common symptom of tuberculosis but may not be one of the first symptoms. Bronchoscopy (D) is a diagnostic procedure and not a symptom of tuberculosis. In summary, chest pain is a common initial symptom due to lung inflammation, while the other choices are either later symptoms or unrelated diagnostic procedures.
If PO2 increases
- A. saturation goes up and hemoglobin stores oxygen
- B. hemoglobin stores oxygen
- C. hemoglobin gives away oxygen
- D. saturation goes up
Correct Answer: A
Rationale: Step 1: Increased PO2 leads to higher oxygen levels in blood.
Step 2: Higher PO2 causes hemoglobin to become fully saturated with oxygen.
Step 3: Fully saturated hemoglobin stores more oxygen.
Step 4: Therefore, as PO2 increases, saturation goes up and hemoglobin stores more oxygen. Other choices are incorrect because they do not align with the relationship between PO2, hemoglobin saturation, and oxygen storage in the blood.