Nokea
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
- A. Call the physician to reinsert the tube.
- B. Grasp the retention sutures to spread the opening.
- C. Call the respiratory therapy department to reinsert the tracheotomy.
- D. Cover the tracheostomy site with a sterile dressing to prevent infection.
Correct Answer: B
Rationale: The correct initial nursing action is to choose option B: Grasp the retention sutures to spread the opening. This is because spreading the opening using the retention sutures can help maintain the airway patency until the tube is reinserted. Calling the physician (option A) or respiratory therapy department (option C) may cause delays in addressing the immediate airway obstruction. Covering the tracheostomy site with a sterile dressing (option D) does not address the primary concern of maintaining the airway. Therefore, option B is the most appropriate and effective action to take in this situation.
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Each of the following is true regarding the spleen, except:
- A. Spleen is located posterolateral to the stomach, and contacts the diaphragm and left kidney.
- B. Splenic veins, arteries, and lymphatic vessels communicate with the spleen at the hilum.
- C. The spleen is a primary lymphoid organ, serving to filter lymph fluid.
- D. Lymphocytes and dendritic cells are concentrated in the white pulp.
Correct Answer: C
Rationale: Rationale:
C is correct because the spleen is a secondary lymphoid organ, not a primary one. The spleen filters blood, not lymph fluid.
A is correct as the spleen is located in the described position.
B is correct as the splenic vessels do communicate with the spleen at the hilum.
D is correct as lymphocytes and dendritic cells are indeed concentrated in the white pulp.
Summary:
A, B, and D are correct statements about the spleen. C is incorrect because the spleen is a secondary lymphoid organ, not a primary one.
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?
- A. Assess the client's pain level.
- B. Keep the client's head elevated.
- C. Teach the client about the causes of nasal bleeding.
- D. Assess the client's airway.
Correct Answer: D
Rationale: The correct answer is D: Assess the client's airway. This is the priority action as airway patency is always the top priority in any emergency situation. In this case, posterior nasal bleeding can lead to blood flow into the throat, potentially obstructing the airway. Ensuring the client's airway is clear and maintaining adequate oxygenation is crucial for their safety.
Choice A (Assess the client's pain level) is not the priority when there is a potential risk to the airway. Choice B (Keep the client's head elevated) may be done after confirming airway patency. Choice C (Teach the client about the causes of nasal bleeding) is important but not the immediate priority in this situation.
What is heart failure?
- A. A sudden stoppage of the heart
- B. Inability of the heart to pump blood effectively
- C. Accumulation of excess cholesterol in the arteries
- D. Irregular heartbeat
Correct Answer: B
Rationale: The correct answer is B: Inability of the heart to pump blood effectively. Heart failure occurs when the heart is unable to pump blood efficiently to meet the body's needs. This can lead to symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation:
1. Heart failure is a chronic condition that develops over time due to various factors such as high blood pressure, heart attacks, or heart muscle damage.
2. The inability of the heart to pump blood effectively results in reduced blood flow to the body's organs and tissues.
3. This can lead to a buildup of fluid in the lungs and other parts of the body, causing symptoms like shortness of breath and swelling.
4. A sudden stoppage of the heart (Choice A) would result in cardiac arrest, not heart failure.
5. Accumulation of excess cholesterol in the arteries (Choice C) refers to atherosclerosis, not heart failure.
6. An irregular heartbeat (Choice D) may be a symptom
The combination of Hemoglobin with Oxygen in the blood can be promoted by
- A. Decreasing O2 concentration
- B. Increasing O2 concentration
- C. Increasing CO2 concentration
- D. Decreasing CO2 concentration
Correct Answer: B
Rationale: The correct answer is B: Increasing O2 concentration. When O2 concentration increases, it promotes the binding of oxygen to hemoglobin in the blood through the process of oxygenation. This results in the formation of oxyhemoglobin, which enhances oxygen transport in the blood.
Summary:
- A: Decreasing O2 concentration would hinder the binding of oxygen to hemoglobin, reducing oxygen transport efficiency.
- C: Increasing CO2 concentration would lead to the formation of carbaminohemoglobin, not oxyhemoglobin.
- D: Decreasing CO2 concentration would not directly promote the binding of oxygen to hemoglobin.
As the nurse responsible for this client's care, you anticipate which physician's orders?
- A. Endotracheal intubation and mechanical ventilation
- B. Immediate application of CPAP to client's nose and mouth
- C. Intravenous furosemide (Lasix) 100 mg IV push stat
- D. Call a CODE for respiratory arrest.
Correct Answer: A
Rationale: The correct answer is A. Poor oxygenation despite non-rebreather mask suggests impending respiratory failure, necessitating intubation and mechanical ventilation. CPAP (B) and Lasix (C) may be considered but are secondary. Calling a CODE (D) is only if respiratory arrest occurs.