Nokea
Why is it important for a nurse to move a victim of a common respiratory toxin to higher ground immediately?
- A. The toxins flow to the lower ground.
- B. The toxic vapors stay close to the ground.
- C. The toxins are always released close to the ground.
- D. The heavy and the solid toxins cannot move to a height.
Correct Answer: B
Rationale: The correct answer is B because many respiratory toxins are heavier than air and settle near the ground.
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A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly
apneic episodes. Which of the following client statements indicates an understanding of the teaching?
- A. "It might help if I tried sleeping only on my back."
- B. "I'll sleep better if I take a sleeping pill at night."
- C. "I'll get a humidifier to run at my bedside at night."
- D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Correct Answer: D
Rationale: The correct answer is D because losing weight can help reduce the severity and frequency of obstructive sleep apnea. Excess weight can lead to fat deposits around the upper airway, causing obstruction during sleep. By losing weight, the airway may become less obstructed, reducing apneic episodes.
Choice A is incorrect because sleeping on the back can actually worsen sleep apnea by causing the tongue and soft tissues to block the airway.
Choice B is incorrect because sleeping pills can relax the muscles in the airway, making it more likely for an individual with sleep apnea to experience episodes of apnea.
Choice C is incorrect because while a humidifier can alleviate some symptoms like dryness, it does not directly address the underlying cause of obstructive sleep apnea related to obesity.
The main goal of treatment for acute glomerulonephritis is to
- A. encourage activity.
- B. encourage high protein intake.
- C. maintain fluid balance.
- D. teach intermittent urinary catheterization.
Correct Answer: C
Rationale: Maintaining fluid balance is critical in managing acute glomerulonephritis due to potential fluid overload.
A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct Answer: C
Rationale: The correct answer is C: Cheyne-Stokes respirations. This breathing pattern is characterized by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations (A) are deep and rapid breathing associated with metabolic acidosis. Apneustic respirations (B) are characterized by prolonged inhalation and short, insufficient exhalation. Stridor (D) is a high-pitched, noisy breathing sound caused by obstructed air flow in the upper airway, not associated with the described breathing pattern.
A 44-year-old female client had an emergency cholecystectomy three days ago for a ruptured gallbladder. The client has severe abdominal pain, abdominal rigidity, distension, increased temperature, tachycardia and an elevated white blood count (WBC). The client has probably developed:
- A. gastritis.
- B. evisceration.
- C. peritonitis.
- D. a pulmonary embolism.
Correct Answer: C
Rationale: Assessment findings of gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity, which causes infection and irritation. Assessment findings of a pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing, often accompanied by blood-tinged sputum.
What volume of fluid loss causes marked deterioration in hypovolemic shock?
- A. 30% to 40% (1500 mL to 2000 mL)
- B. 15% to 30% (750 mL to 1500 mL)
- C. 10% to 15% (500 mL to 750 mL)
- D. More than 40% (more than 2000 mL)
Correct Answer: B
Rationale: Loss of 15% to 30% of blood volume significantly impairs circulation and tissue perfusion.