Nokea
Which of the following does the examiner note when auscultating the lungs of a client with pleural effusion?
- A. Pronounced breath sounds
- B. Friction rub
- C. Expiratory wheezes
- D. Fluid in the involved area
Correct Answer: D
Rationale: The correct answer is D. Fluid in the pleural space muffles breath sounds and may be noted during auscultation. A (pronounced breath sounds) is incorrect as they are diminished in pleural effusion. B (friction rub) occurs in pleuritis, not effusion. C (expiratory wheezes) indicates airway obstruction, not fluid accumulation.
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Which statement is NOT true?
- A. Carbon dioxide is more soluble in fluid than in oxygen.
- B. Carbon dioxide diffuses more rapidly across the respiratory surface than does oxygen.
- C. The major muscle involved in breathing is the diaphragm.
- D. Oxygen is carried primarily by blood plasma
Correct Answer: D
Rationale: The correct answer is D. Oxygen is primarily carried by hemoglobin in red blood cells, not blood plasma. Hemoglobin binds to oxygen, forming oxyhemoglobin for transport. Option A is false because oxygen is more soluble in fluid than carbon dioxide. Option B is incorrect as oxygen diffuses slower than carbon dioxide due to its larger molecular size. Option C is true as the diaphragm is the main muscle involved in breathing, contracting to expand the lungs during inhalation.
What is heart failure?
- A. A sudden stoppage of the heart
- B. Inability of the heart to pump blood effectively
- C. Accumulation of excess cholesterol in the arteries
- D. Irregular heartbeat
Correct Answer: B
Rationale: The correct answer is B: Inability of the heart to pump blood effectively. Heart failure occurs when the heart is unable to pump blood efficiently to meet the body's needs. This can lead to symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation:
1. Heart failure is a chronic condition that develops over time due to various factors such as high blood pressure, heart attacks, or heart muscle damage.
2. The inability of the heart to pump blood effectively results in reduced blood flow to the body's organs and tissues.
3. This can lead to a buildup of fluid in the lungs and other parts of the body, causing symptoms like shortness of breath and swelling.
4. A sudden stoppage of the heart (Choice A) would result in cardiac arrest, not heart failure.
5. Accumulation of excess cholesterol in the arteries (Choice C) refers to atherosclerosis, not heart failure.
6. An irregular heartbeat (Choice D) may be a symptom
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.
Information from chemoreceptors travels to the brain via the ________ nerves.
- A. trigeminal
- B. hypoglossal
- C. vagus and glossopharyngeal
- D. glossopharyngeal
Correct Answer: C
Rationale: The correct answer is C, vagus and glossopharyngeal nerves. Chemoreceptors in the carotid bodies and aortic bodies detect changes in blood chemistry and send signals to the brainstem. The glossopharyngeal nerve carries signals from the carotid bodies, while the vagus nerve carries signals from the aortic bodies. These signals are crucial for regulating breathing and maintaining homeostasis. The other choices, trigeminal (A) and hypoglossal (B) nerves, are not involved in transmitting signals from chemoreceptors to the brain. Choice D, glossopharyngeal nerve alone, is not correct as both glossopharyngeal and vagus nerves are involved in this process.