Nokea
Which of the following is NOT found in lung tissue?
- A. blood capillaries
- B. alveolar sacs
- C. interstitial fluid
- D. muscle
Correct Answer: D
Rationale: The correct answer is D: muscle. Lung tissue does not contain muscle tissue; instead, it is primarily composed of alveolar sacs for gas exchange, blood capillaries for oxygen exchange, and interstitial fluid for support. Muscles are not part of the structure of the lungs as they are not involved in the respiratory process. In summary, muscles are not found in lung tissue, making option D the correct choice.
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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.
What is the most effective treatment for cystic fibrosis?
- A. Heart-lung transplant
- B. Administration of prophylactic antibiotics
- C. Administration of nebulized bronchodilators
- D. Vigorous and consistent chest physiotherapy
Correct Answer: D
Rationale: The most effective treatment for cystic fibrosis is vigorous and consistent chest physiotherapy, as it helps in clearing the mucus and improving lung function.
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a few days ago" and shows the nurse the results of what the client calls an allergy test" as shown below: The reddened area is firm. What action by the nurse is best?
- A. Call the primary health care provider's office to request records.
- B. Immediately place the client on Airborne Precautions.
- C. Prepare to begin administration of intravenous antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Prepare to begin administration of intravenous antibiotics. This is the best action because the client is suspected of having pneumonia, which is commonly treated with antibiotics. The nurse should prepare to start IV antibiotics to address the infection promptly.
Choice A is incorrect because requesting records from the primary health care provider's office may delay treatment. Choice B is incorrect because airborne precautions are not necessary for suspected pneumonia. Choice D is incomplete and does not provide a clear action plan for addressing the client's condition.
The nurse assesses wheezes in a patient with asthma and realizes that these breath sounds result from:
- A. Increased thickness of respiratory secretions.
- B. Use of accessory muscles of respiration.
- C. Tachypnea and tachycardia.
- D. Movement of air through narrowed airways.
Correct Answer: D
Rationale: The correct answer is D because wheezes in asthma are caused by the movement of air through narrowed airways due to bronchoconstriction and inflammation. This narrowing leads to turbulent airflow, resulting in the characteristic high-pitched musical sound of wheezes. Increased thickness of respiratory secretions (A) may cause crackles, not wheezes. Use of accessory muscles (B) indicates respiratory distress but does not directly cause wheezes. Tachypnea and tachycardia (C) are common in asthma but do not directly cause wheezes. Thus, D is the most directly related to the pathophysiology of wheezes in asthma.
which of the following is a chronic respiratory disorder caused by smoking?
- A. asthma
- B. emphysema
- C. respiratory alkalosis
- D. Acidosis
Correct Answer: B
Rationale: Emphysema is the correct answer because it is a chronic respiratory disorder specifically caused by smoking. Smoking damages the air sacs in the lungs, leading to shortness of breath and difficulty breathing. Asthma is a separate condition involving airway inflammation. Respiratory alkalosis and acidosis refer to imbalances in blood pH levels, not directly caused by smoking.