Nokea
Which area represents the work to overcome airway resistance?
- A. ABCEA
- B. ABCFA
- C. AECFA
- D. ABCDOA
Correct Answer: C
Rationale: The correct answer is C: AECFA. This sequence represents the flow of air through the respiratory system. Airway resistance is primarily overcome by the contraction and relaxation of the smooth muscles in the airways. The correct sequence includes the airway segments that actively participate in regulating airway resistance - the trachea (A), bronchi (E), and bronchioles (C and F). The other choices do not include the correct segments that are involved in overcoming airway resistance.
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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.
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
- A. Call the physician to reinsert the tube.
- B. Grasp the retention sutures to spread the opening.
- C. Call the respiratory therapy department to reinsert the tracheotomy.
- D. Cover the tracheostomy site with a sterile dressing to prevent infection.
Correct Answer: B
Rationale: The correct initial nursing action is to choose option B: Grasp the retention sutures to spread the opening. This is because spreading the opening using the retention sutures can help maintain the airway patency until the tube is reinserted. Calling the physician (option A) or respiratory therapy department (option C) may cause delays in addressing the immediate airway obstruction. Covering the tracheostomy site with a sterile dressing (option D) does not address the primary concern of maintaining the airway. Therefore, option B is the most appropriate and effective action to take in this situation.
In the lungs
- A. PCO2 in the alveoli is the same as that in the capillaries
- B. PO2 in the alveoli is the same as that in the capillaries
- C. PCO2 in the alveoli is higher than that in the capillaries
- D. PCO2 in the alveoli is lower than that in the capillaries
Correct Answer: D
Rationale: The correct answer is D because in the lungs, during gas exchange, carbon dioxide (CO2) is removed from the blood and exhaled. This leads to a lower PCO2 in the alveoli compared to the capillaries. The concentration gradient drives the diffusion of CO2 from the capillaries to the alveoli. Options A and B are incorrect because the partial pressure of CO2 (PCO2) and oxygen (PO2) differ between the alveoli and capillaries due to gas exchange. Option C is also incorrect as PCO2 is lower in the alveoli to facilitate the removal of CO2 from the blood.
A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. What is an expected outcome for this patient?
- A. SpO is 90%
- B. Lungs clear to auscultation
- C. Patient tolerates walking in hallway
- D. Patient takes three or four shallow breaths before coughing to minimize pain
Correct Answer: D
Rationale: The expected outcome for a patient with ineffective airway clearance would be for the patient to take three or four shallow breaths before coughing to minimize pain, which indicates effective clearing of airway secretions. The other options do not directly relate to the nursing diagnosis provided.
The nurse is caring for a client who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
- A. O2 saturation is 88%
- B. Blood pressure is 155/90 mm Hg.
- C. Respiratory rate is 24 breaths/min when lying flat.
- D. Pain level is 5 (on 0 to 10 scale) with a deep breath.
Correct Answer: A
Rationale: The correct answer is A because a low O2 saturation level (88%) indicates potential respiratory compromise or hypoxemia post-thoracentesis, which requires immediate intervention to prevent hypoxia. The other choices are not as critical: B (BP slightly elevated but not urgent), C (RR slightly elevated but expected after procedure), and D (Pain at level 5 with deep breath is common post-thoracentesis and can be managed).