Nokea
Which patient assessment indicates the most severe respiratory distress?
- A. Nasal flaring, symmetrical chest wall expansion, SaO2 88%
- B. Abdominal breathing, SaO2 97%
- C. Substernal retraction, SaO2 84%
- D. Substernal retraction, SaO2 90%
Correct Answer: C
Rationale: Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress.
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The patient has advanced emphysema and reports experiencing dyspnea and fatigue. Which nursing intervention would be appropriate for the patient who is having difficulty with activity tolerance?
- A. Direct patient in vigorous independent ROM.
- B. Allow to exercise until respirations are over 20 breaths/min over baseline.
- C. Plan care to provide optimum rest.
- D. Provide frequent cool showers.
Correct Answer: C
Rationale: Nursing interventions will be directed at attempting to decrease the patient's anxiety and promote optimal air exchange. The nurse should allow sufficient rest periods and should assist the patient in activities of daily living.
The nurse assessing an 11 year old who is having an asthma attack expects to hear which adventitious sounds?
- A. Friction rub.
- B. Expiratory wheezes
- C. Crackles.
- D. Absent breath sounds.
Correct Answer: B
Rationale: The narrowed bronchioles characteristic of an asthma attack would produce wheezes, which are high-pitched whistling sounds.
Which nursing intervention is for a patient, age 40, who is diagnosed with active tuberculosis?
- A. Place the patient in drainage and secretion precautions.
- B. Place the patient in acid-fast bacillus (AFB) Isolation Precautions.
- C. Maintain the patient in enteric isolation.
- D. Place the patient in any Isolation Precautions.
Correct Answer: B
Rationale: If TB is suspected, place the patient in acid-fast bacillus (AFB) Isolation Precautions immediately.
Which feature is a major advantage of video-assisted thoracoscopic surgery (VATS)?
- A. The surgeon can record entire surgical procedure on a video.
- B. The surgeon can remove tumors of the lung through a small keyhole incision.
- C. The surgeon can x-ray and excise tumor in the same procedure.
- D. The surgeon can avoid the use of a closed chest drainage system after surgery.
Correct Answer: B
Rationale: The video-assisted thoracoscopic surgery allows surgeons to remove tumors through a small keyhole incision. Although the incisions are small, a closed chest drainage system will still be necessary after the surgery.
In which way do leukotriene modifiers reduce the symptoms of asthma?
- A. By drying up mucus
- B. By causing bronchodilation and anti-inflammation effects
- C. By suppressing cough
- D. By liquefying mucus
Correct Answer: B
Rationale: Leukotriene modifiers reduce the symptoms of asthma by causing bronchodilation and anti-inflammatory processes.