Nokea
Which vital sign should she immediately report to you—the RN?
- A. Heart rate 98 per minute
- B. Respiratory rate 24 per minute
- C. Blood pressure 168/90
- D. Tympanic temperature 101.4°F
Correct Answer: D
Rationale: The correct answer is D. A temperature of 101.4°F indicates possible infection or complication and requires immediate attention. Heart rate (A), respiratory rate (B), and blood pressure (C) are within acceptable ranges post-suctioning.
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Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?
- A. Hypocapnia
- B. A hyperinflated chest noted on the chest x-ray.
- C. Increased oxygen saturation with exercise.
- D. A widened diaphragm noted on the chest x-ray.
Correct Answer: B
Rationale: The correct answer is B: A hyperinflated chest noted on the chest x-ray. In COPD, air trapping leads to hyperinflation of the lungs, causing the chest to appear hyperinflated on x-ray. This is due to the increased residual volume and decreased expiratory flow rates in COPD.
Incorrect choices:
A: Hypocapnia is unlikely in COPD as patients typically retain carbon dioxide due to impaired gas exchange.
C: Increased oxygen saturation with exercise is unlikely in COPD as these patients often have decreased oxygen saturation due to impaired gas exchange.
D: A widened diaphragm would not be a typical finding on chest x-ray in COPD; hyperinflated lungs are more characteristic.
An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?
- A. Assess the client's lung sounds.
- B. Assign a different AP to the client.
- C. Report the AP to the manager.
- D. Request thicker liquids for meals.
Correct Answer: A
Rationale: Correct Answer: A - Assess the client's lung sounds.
Rationale:
1. Assessing lung sounds helps determine if the client is experiencing respiratory distress.
2. Coughing during a meal with a tracheostomy can indicate aspiration or airway obstruction.
3. Prompt assessment can prevent potential complications and guide further interventions.
Summary:
- B: Assigning a different AP does not address the client's immediate respiratory status.
- C: Reporting the AP to the manager is not necessary before assessing the client's condition.
- D: Requesting thicker liquids does not address the underlying issue of potential aspiration or airway obstruction.
A sensitized B cell is activated once:
- A. it binds a helper T cell that releases cytokines.
- B. it binds a cytotoxic T cell.
- C. memory B cells have been cloned.
- D. it has cloned plasma cells.
Correct Answer: A
Rationale: The correct answer is A because a sensitized B cell requires activation by a helper T cell releasing cytokines to undergo differentiation and proliferation into plasma cells. This interaction is crucial for initiating the humoral immune response. Choices B, C, and D are incorrect because binding to a cytotoxic T cell, cloning of memory B cells, or cloning of plasma cells do not directly activate a sensitized B cell for its function in producing antibodies.
Fick's law of diffusion is related to
- A. Diffusion and Surface area
- B. Diffusion and membrane potential
- C. Diffusion and water content
- D. Diffusion and pore diameter
Correct Answer: A
Rationale: Fick's law of diffusion states that the rate of diffusion is directly proportional to the surface area and concentration gradient, and inversely proportional to the distance over which diffusion occurs. Therefore, Choice A - Diffusion and Surface area is correct because surface area directly affects the rate of diffusion. Choices B, C, and D are incorrect as they do not directly relate to Fick's law. B is incorrect as membrane potential is not a factor in Fick's law. C is incorrect as water content is not a key factor in the law of diffusion. D is incorrect as pore diameter is not explicitly mentioned in Fick's law.
The metal associated with haemoglobin is
- A. Sodium
- B. Potassium
- C. Calcium
- D. Iron
Correct Answer: D
Rationale: The correct answer is D: Iron. Haemoglobin is a protein in red blood cells that carries oxygen throughout the body. Iron is an essential component of haemoglobin, binding to oxygen molecules and facilitating their transport. Sodium, potassium, and calcium do not play a direct role in the structure or function of haemoglobin, making them incorrect choices. Iron deficiency can lead to anemia due to the lack of adequate oxygen-carrying capacity in the blood.