Nokea
While assessing an older adult patient, what finding indicates left-sided heart failure?
- A. Weight gain
- B. Ascites
- C. Crackles
- D. Jugular vein distention
Correct Answer: C
Rationale: The correct answer is C: Crackles. Crackles indicate left-sided heart failure due to fluid accumulation in the lungs. This occurs when the left side of the heart is unable to efficiently pump blood, leading to fluid backing up into the lungs. Weight gain (A) may be a general sign of heart failure but is not specific to left-sided failure. Ascites (B) is more indicative of right-sided heart failure, where fluid accumulates in the abdomen. Jugular vein distention (D) is a sign of right-sided heart failure, where blood backs up into the systemic circulation causing jugular vein distention.
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Which of the following symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
- A. Pain when talking
- B. Burning in the throat
- C. Increased nasal swelling
- D. Presence of laryngospasm
Correct Answer: D
Rationale: The correct answer is D. Laryngospasm is a serious symptom that requires immediate attention in upper airway trauma. A (pain when talking) and B (burning in the throat) are less urgent. C (increased nasal swelling) is a local finding but not life-threatening.
Hiccup is due to
- A. Increased inspiration
- B. Irritation of Phrenic nerve
- C. Expanded stomach
- D. Acidity in the stomach
Correct Answer: B
Rationale: The correct answer is B because hiccups are caused by the irritation of the phrenic nerve, which controls the diaphragm muscle responsible for breathing. When the nerve is irritated, it causes the diaphragm to contract involuntarily, leading to the characteristic sound of hiccups.
Choice A (Increased inspiration) is incorrect as hiccups are not caused by increased inspiration but rather by involuntary contractions of the diaphragm.
Choice C (Expanded stomach) is incorrect as hiccups are not directly related to the size of the stomach but rather to nerve irritation.
Choice D (Acidity in the stomach) is incorrect as hiccups are not primarily caused by stomach acidity, but by nerve irritation leading to diaphragm contractions.
Air that remains in conducting passages and doesn't participate in gas exchange is termed
- A. vital capacity
- B. minimal volume
- C. residual volume
- D. anatomic dead space
Correct Answer: D
Rationale: The correct answer is D: anatomic dead space. Anatomic dead space refers to the air in the conducting passages (such as trachea, bronchi) that does not reach the alveoli for gas exchange. This space only serves as a pathway for air to move in and out of the lungs. Vital capacity (A) is the maximum amount of air that can be exhaled after a maximum inhalation. Minimal volume (B) is not a recognized term in respiratory physiology. Residual volume (C) is the amount of air left in the lungs after a maximal exhalation and is not specifically related to the air in conducting passages.
Regarding ventilation
- A. Normal FEV1 is 70% of FVC
- B. FEV1 is decreased much more than FVC in patients with lung fibrosis
- C. FEV1 is dependent on expiratory effort
- D. FEV1 is about 42% of FVC in a patient with obstructive lung disease
Correct Answer: D
Rationale: The correct answer is D because in obstructive lung diseases like COPD, FEV1 is reduced compared to FVC due to air trapping. This is a characteristic feature of obstruction. A: Incorrect, normal FEV1/FVC ratio is around 80-85%. B: Incorrect, in lung fibrosis, both FEV1 and FVC are reduced but the reduction in FVC is typically more prominent. C: Incorrect, while expiratory effort affects FEV1 maneuver, it is not the sole determinant.
A 68-year-old male is being admitted to the hospital for an exacerbation of his COPD. The nurse is developing his plan of care. The nurse can expect that this client will?
- A. Be placed on 10 L of oxygen per nasal cannula.
- B. Be placed in respiratory isolation.
- C. Require frequent rest periods throughout the day.
- D. Be placed on fluid restriction.
Correct Answer: C
Rationale: The correct answer is C: Require frequent rest periods throughout the day. This is because patients with COPD often experience shortness of breath and fatigue, necessitating frequent rest periods to conserve energy and manage symptoms. Oxygen therapy is typically started at a lower flow rate (2-4 L/min) to avoid suppressing the patient's respiratory drive, so option A is not appropriate. Respiratory isolation is unnecessary for COPD exacerbation, as it is not a contagious condition, making option B incorrect. Fluid restriction is not typically indicated for COPD exacerbation unless the patient has comorbid conditions like heart failure, so option D is not the priority.