Nokea
Which of these assessments made by the nurse indicates that respiratory arrest is imminent in an asthmatic?
- A. Agitation.
- B. Tachycardia.
- C. Absence of wheezing.
- D. Flaring nares.
Correct Answer: C
Rationale: The correct answer is C: Absence of wheezing. In asthmatics, wheezing is a common sign of airway obstruction. The absence of wheezing indicates a severe obstruction leading to reduced airflow, which can progress to respiratory arrest. Agitation (A) and tachycardia (B) are common signs of distress but do not specifically indicate imminent respiratory arrest. Flaring nares (D) may suggest increased work of breathing, but it is not as specific as the absence of wheezing in predicting imminent respiratory arrest in asthmatics.
You may also like to solve these questions
Which diagnostic test is commonly used to assess heart function in heart failure?
- A. Electrocardiogram (ECG or EKG)
- B. Magnetic Resonance Imaging (MRI)
- C. Colonoscopy
- D. Blood glucose test
Correct Answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG or EKG). An ECG is commonly used to assess heart function in heart failure because it provides information on the heart's electrical activity, rhythm, and any abnormalities. It can detect conditions such as arrhythmias, ischemia, and previous heart attacks. Other choices are incorrect: B (MRI) is more for imaging the structure of the heart, C (Colonoscopy) is for examining the colon, and D (Blood glucose test) is for measuring blood sugar levels, not heart function.
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.
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.
Which respiratory division includes the larynx and respiratory structures distal?
- A. upper respiratory tract.
- B. lower respiratory tract.
- C. internal respiratory tract.
- D. alveoli of the respiratory tract.
Correct Answer: B
Rationale: The correct answer is B, lower respiratory tract. The larynx and structures distal to it, such as the trachea, bronchi, and lungs, are part of the lower respiratory tract. The upper respiratory tract (choice A) includes the nose, nasal cavity, pharynx, and larynx. Internal respiratory tract (choice C) is not a commonly used term in respiratory anatomy. Alveoli of the respiratory tract (choice D) specifically refer to the air sacs in the lungs where gas exchange occurs, not the entire respiratory division that includes the larynx and structures distal to it.
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.