A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient?

Correct Answer: A

Rationale: If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Consider this as normal findings. In a water-seal drainage system with suction, continuous bubbling and oscillation are expected findings that indicate the system is functioning properly. The bubbling occurs due to the movement of air and fluid in the system, while oscillation indicates the fluctuation of pressure within the system. Option B) Notify the physician is incorrect because these findings do not necessarily indicate a problem that requires immediate physician notification. Understanding the normal functioning of the drainage system will help prevent unnecessary alarm and interventions. Option C) Check for tube leak is incorrect because continuous bubbling and oscillation do not automatically indicate a tube leak. These are common occurrences in a water-seal drainage system with suction. Option D) Prepare a petrolatum gauze dressing is incorrect because this action is not warranted based on the information provided. Applying a dressing in this situation would not address the underlying cause of the bubbling and oscillation. Educational Context: As a nurse, it is crucial to have a solid understanding of the principles and function of drainage systems used in patient care. Recognizing normal findings in these systems helps prevent unnecessary interventions and ensures appropriate patient care. Continuous education and training on medical devices and equipment used in nursing practice can enhance clinical judgment and decision-making skills.

Correct Answer: A

Rationale: In the context of oxygenation and nursing practice, understanding the role of vitamins in maintaining optimal health is crucial. In this question, the correct answer is A) Vitamin B1. Thiamine, also known as Vitamin B1, is essential for the body's energy metabolism and proper functioning of the nervous system. Beri-beri is a condition caused by a deficiency of Vitamin B1, leading to symptoms such as neurological issues and cardiovascular abnormalities. Therefore, choosing option A as the correct answer is imperative for nurses to recognize the relationship between Vitamin B1 deficiency and the development of beri-beri. Option B) Vitamin B2 (riboflavin) is incorrect because Vitamin B2 deficiency typically manifests as skin disorders and oral health problems, not as beri-beri. Option C) Vitamin B3 (niacin) deficiency leads to pellagra, characterized by dermatitis, diarrhea, and dementia, but not beri-beri. Option D) Vitamin C deficiency results in scurvy, which primarily presents with symptoms such as gum disease and skin issues, rather than the neurological and cardiovascular symptoms seen in beri-beri. In the nursing field, understanding the specific roles of vitamins and their associated deficiency conditions is essential for providing quality patient care. By grasping the connection between Vitamin B1 deficiency and beri-beri, nurses can identify symptoms early, provide appropriate interventions, and educate patients on preventive measures. This knowledge ultimately enhances the nurse's ability to promote effective oxygenation and overall patient well-being.

Correct Answer: B

Rationale: In the context of NGT insertion, the correct answer is B, which involves measuring the length of the tube to be inserted from the tip of the nose, to the earlobe, to the xiphoid process. This method ensures that the NGT is of the appropriate length for gastric placement, preventing complications such as lung insertion or inadequate placement. Option A is incorrect because using an oil-based lubricant can be harmful if aspirated into the lungs. Option C is incorrect as soaking the NGT in ice water can cause vasoconstriction and make the tube rigid, making insertion difficult and uncomfortable for the patient. Option D is incorrect because auscultation for a bubbling sound is not a reliable method for verifying NGT placement, as it can lead to inaccurate results. Educationally, understanding the correct technique for NGT insertion is crucial for nurses to ensure safe and effective patient care. Teaching proper NGT insertion procedures can help prevent potential complications and ensure accurate placement, thus promoting optimal patient outcomes. Nurses must be knowledgeable about evidence-based practices to provide high-quality care and ensure patient safety during NGT insertion procedures.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Over-distention, inelasticity, and rupture of alveoli. Emphysema is a chronic pulmonary disease characterized by the destruction of the alveolar walls, leading to the enlargement of air spaces and loss of elasticity in the lungs. Over time, these changes result in the decreased surface area available for gas exchange and impaired oxygenation. The alveolar over-distention, inelasticity, and rupture contribute to air trapping and difficulty exhaling in patients with emphysema. Option B) Accumulation of pus in the pleural cavity is characteristic of conditions like empyema, which is an infection involving pus in the pleural space and not specific to emphysema. Option C) Feeling of air passageway inflammatory alveoli does not accurately describe the pathophysiology of emphysema. Emphysema is primarily a disease of the alveoli and not the air passageways. Option D) Accumulation of fluid in the pleural sac is more indicative of conditions like pleural effusion, where there is an abnormal accumulation of fluid in the pleural space, not a feature of emphysema. Educational Context: Understanding the characteristic tissue changes seen in emphysema is crucial for nurses caring for patients with respiratory conditions. By recognizing the pathophysiological changes of emphysema, nurses can provide appropriate care, education, and support to patients with this condition. Nurses play a vital role in the management of respiratory diseases, including emphysema, by promoting optimal oxygenation, providing education on breathing techniques, and assisting with symptom management. Recognizing the specific tissue changes in emphysema helps nurses tailor their care to meet the individualized needs of each patient.