Nokea
Which assessment findings aren't consistent with a client diagnosis of right-sided heart failure?
- A. Collapsed neck veins
- B. Distended abdomen
- C. Dependent edema
- D. Decreased appetite
Correct Answer: A
Rationale: The correct answer is A because collapsed neck veins are not consistent with right-sided heart failure. In right-sided heart failure, venous congestion leads to jugular venous distention, not collapse. Distended abdomen (choice B) occurs due to fluid accumulation in the abdomen, a common finding in right-sided heart failure. Dependent edema (choice C) results from fluid retention in the lower extremities, also seen in right-sided heart failure. Decreased appetite (choice D) can be present due to abdominal discomfort from fluid accumulation. Therefore, the presence of collapsed neck veins is the only assessment finding that is not indicative of right-sided heart failure.
You may also like to solve these questions
Spirometry is used
- A. To detect the amount of Hemoglobin
- B. To detect the air flow through the respiratory system
- C. To check the respiratory quotient
- D. None of these
Correct Answer: B
Rationale: The correct answer is B: To detect the air flow through the respiratory system. Spirometry measures lung function by assessing the volume of air inhaled and exhaled. It helps in diagnosing respiratory conditions like asthma or COPD. Choice A is incorrect because spirometry does not measure hemoglobin levels. Choice C is incorrect as spirometry does not determine the respiratory quotient, which relates to metabolic processes. Choice D is incorrect as spirometry is used for assessing respiratory function.
While assessing an acutely ill patient's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?
- A. Eupnea
- B. Apnea
- C. Biot's respiration
- D. Cheyne-Stokes
Correct Answer: C
Rationale: The correct answer is C: Biot's respiration. Biot's respiration is characterized by regular breathing interrupted by periods of apnea. In this scenario, the nurse observed normal breaths followed by a 20-second episode of apnea, which aligns with Biot's respiration. It is crucial to document this finding accurately to ensure appropriate care.
Incorrect answers:
A: Eupnea refers to normal breathing without any interruptions or irregularities. The presence of apnea in the scenario rules out eupnea.
B: Apnea would be an incomplete assessment as it does not capture the alternating pattern of normal breaths and apnea observed in Biot's respiration.
D: Cheyne-Stokes breathing involves a cyclical pattern of gradually increasing and decreasing breathing rates, which is not evident in the scenario described.
Under quiet conditions, blood returning to the heart retains about ________ of its oxygen content.
- A. 25 percent
- B. 50 percent
- C. 75 percent
- D. 90 percent
Correct Answer: C
Rationale: The correct answer is C (75 percent) because under quiet conditions, the venous blood returning to the heart still contains a significant amount of oxygen due to the efficient extraction of oxygen by tissues. This oxygen extraction process typically leaves around 25 percent of oxygen in the venous blood, which is then returned to the heart. Choices A (25 percent), B (50 percent), and D (90 percent) are incorrect because they do not accurately reflect the amount of oxygen retained in the blood under quiet conditions. Option A (25 percent) is the amount typically extracted by tissues, so it cannot be the correct answer. Option B (50 percent) is too high, as more oxygen is extracted by tissues. Option D (90 percent) is also too high, as it overestimates the amount of oxygen retained in venous blood.
The covering of the lung is called
- A. Pericardium
- B. Perichondrium
- C. Pleural membrane/ pleura
- D. Peritoneum
Correct Answer: C
Rationale: The correct answer is C: Pleural membrane/pleura. The pleural membrane is a double-layered serous membrane that covers the lungs. The visceral pleura is attached to the lung surface, while the parietal pleura lines the chest cavity. This arrangement helps reduce friction and allows the lungs to expand during breathing.
A: Pericardium covers the heart, not the lungs.
B: Perichondrium covers cartilage, not the lungs.
D: Peritoneum covers abdominal organs, not the lungs.
Therefore, the correct choice is C because it specifically refers to the covering of the lungs.
Which of the following lymphocytes are involved in innate immunity?
- A. natural killer (NK) cells
- B. plasma cells
- C. CD8 T cells
- D. B memory cells
Correct Answer: A
Rationale: Natural killer (NK) cells are involved in innate immunity as they are able to directly kill virus-infected cells and tumor cells without prior sensitization. They are part of the body's first line of defense against infections. Plasma cells, CD8 T cells, and B memory cells are all part of adaptive immunity, which involves a specific response to pathogens and requires prior exposure. Therefore, they are not involved in innate immunity.