Nokea
Which teaching point is most important for the client with a peritonsillar abscess?
- A. Gargle with warm salt water.
- B. Take all antibiotics as directed.
- C. Let us know if you want liquid medications.
- D. Wash hands frequently.
Correct Answer: B
Rationale: The correct answer is B: Take all antibiotics as directed. This is the most important teaching point for a client with a peritonsillar abscess because antibiotics are crucial in treating the infection and preventing complications. Here's the rationale:
1. Antibiotics target the bacteria causing the abscess, helping to clear the infection.
2. Incomplete antibiotic course can lead to antibiotic resistance and recurrence of infection.
3. Not following antibiotic instructions can result in treatment failure and worsening of the abscess.
4. Gargling with warm salt water (choice A) may provide temporary relief but does not address the underlying infection. Liquid medications (choice C) and handwashing (choice D) are important but not as vital as completing the antibiotic course.
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Dead air is not involved in respiration because
- A. It is very low quantity
- B. It is trapped in nasal passage
- C. It contains less Oxygen
- D. It is present deep in the lungs
Correct Answer: D
Rationale: The correct answer is D because dead air is the air present in the alveoli that does not participate in gas exchange. It is located deep in the lungs, beyond the respiratory bronchioles where gas exchange occurs. Dead air does not reach the alveoli to participate in respiration. Choices A, B, and C are incorrect because the quantity of dead air or its oxygen content are not the primary reasons why it is not involved in respiration.
A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 30, HCO3 20. The nurse analyzes these results as indicating which condition?
- A. Metabolic acidosis, compensated
- B. Respiratory alkalosis, fully compensated
- C. Metabolic alkalosis, uncompensated
- D. Respiratory acidosis, uncompensated
Correct Answer: B
Rationale: The correct answer is B: Respiratory alkalosis, fully compensated. The pH is elevated (alkalosis) at 7.45. The low PCO2 of 30 indicates respiratory alkalosis. The HCO3 level of 20 is slightly below normal, indicating metabolic compensation. The body has compensated for the respiratory alkalosis by reducing the HCO3 level. Choices A, C, and D are incorrect because they do not align with the given ABG results. A (Metabolic acidosis, compensated) would have low pH and HCO3 levels. C (Metabolic alkalosis, uncompensated) would have high pH and HCO3 levels. D (Respiratory acidosis, uncompensated) would have high PCO2 and low pH.
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?
- A. Face mask
- B. Venturi mask
- C. Aerosol mask
- D. Tracheostomy collar
Correct Answer: B
Rationale: The correct answer is B: Venturi mask. The Venturi mask delivers a precise oxygen concentration by mixing oxygen with room air through different sized ports, allowing for accurate oxygen delivery. This is important for patients with COPD who require specific oxygen levels to prevent oxygen toxicity or hypoxemia.
A: Face mask delivers a less precise oxygen concentration and may not be suitable for patients who require exact oxygen levels.
C: Aerosol mask is used for delivering medications or humidified air, not for precise oxygen concentration.
D: Tracheostomy collar is used for patients with a tracheostomy and is not typically used for delivering precise oxygen concentration in COPD.
Which of the following neurological controls of ventilation responds to changes in the pH and levels of oxygen and CO2 in the blood?
- A. Central chemoreceptors in the medulla
- B. Peripheral chemoreceptors in the aortic arch and carotid arteries
- C. Respiratory centers in the medulla oblongata and pons
- D. Central chemoreceptors in the spinal cord
Correct Answer: A
Rationale: The correct answer is A. Central chemoreceptors in the medulla are highly sensitive to changes in pH and CO2 levels, influencing respiratory rate and depth. B is incorrect because peripheral chemoreceptors respond mainly to O2 levels. C refers to general respiratory control centers, not specific chemoreceptor function. D is incorrect as the spinal cord lacks central chemoreceptors.
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?
- A. Call the operating room to inform them of a pending emergency case.
- B. No action is needed at this time; this is a normal finding in some clients.
- C. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
- D. Stay with the client and have someone else call the primary health care provider immediately.
Correct Answer: D
Rationale: The correct answer is D.
1. Pulsation of the tracheostomy tube with the heartbeat indicates a possible vascular anomaly or the tube being in contact with a major vessel.
2. Staying with the client ensures immediate monitoring and intervention if needed.
3. Having someone else call the primary health care provider promptly allows for timely assessment and intervention.
4. Options A, B, and C are incorrect. Option A is premature without assessing the client further. Option B is incorrect as pulsation is not a normal finding in tracheostomy tubes. Option C is unsafe and can lead to airway compromise.