Nursing Elites

1. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?

• A. ''This action of my lips helps to keep my airway open.''
• B. ''I can expel more air when I pucker up my lips to breathe out.''
• C. ''My mouth doesn't get as dry when I breathe with pursed lips.''
• D. ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''

Correct answer: D

Rationale: The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease. Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.

2. When assessing a patient's pulse, which of the following characteristics would the nurse also notice?

• A. Force
• B. Pallor
• C. Capillary refill time
• D. Timing in the cardiac cycle

Correct answer: A

Rationale: When assessing a patient's pulse, the nurse should observe characteristics such as rate, rhythm, and force. Force refers to the strength or amplitude of the pulse, which provides important information about cardiac output. Pallor is the paleness of the skin and is not directly related to pulse assessment. Capillary refill time is used to assess peripheral perfusion and is not specifically part of pulse assessment. Timing in the cardiac cycle is a broader concept and not a characteristic directly assessed during a pulse examination. Therefore, choice A, 'Force,' is the correct answer as it aligns with the standard parameters evaluated during pulse assessment.

3. What technique would the nurse use to accurately assess a rectal temperature in an adult?

• A. Use a lubricated blunt tip thermometer.
• B. Insert the thermometer 2 to 3 inches into the rectum.
• C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
• D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.

Correct answer: A

Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

4. An experienced healthcare professional instructs a new colleague on caring for a patient with dyspnea due to a pulmonary fungal infection. Which action by the new colleague indicates a need for further teaching?

• A. Listening to the patient's lung sounds several times during the shift
• B. Placing the patient in droplet precautions and in a private hospital room
• C. Increasing the oxygen flow rate to maintain oxygen saturation above 90%
• D. Monitoring the patient's serology results to identify the specific infecting organism

Correct answer: B

Rationale: The correct answer is placing the patient in droplet precautions and in a private hospital room. Fungal infections are not transmitted from person to person, so isolation procedures like droplet precautions are unnecessary. Listening to the patient's lung sounds, increasing the oxygen flow rate, and monitoring serology results are all appropriate actions in caring for a patient with dyspnea caused by a pulmonary fungal infection.

5. Which brain structure serves as the heat-regulating center?

• A. Hypothalamus
• B. Pituitary Gland
• C. Pons
• D. Medulla Oblongata

Correct answer: A

Rationale: The correct answer is the Hypothalamus. The hypothalamus is responsible for regulating body temperature, ensuring it stays within a narrow range. Moreover, the hypothalamus controls various essential bodily functions, such as hunger, thirst, and circadian rhythms. Choices B, C, and D are incorrect because the Pituitary Gland primarily produces and releases hormones, the Pons is involved in functions like sleep, respiration, and bladder control, and the Medulla Oblongata controls vital functions like breathing and heart rate, but not body temperature regulation.

Similar Questions