A nurse is caring for a client who has emphysema.
Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)
Bradycardia.
Dyspnea.
Deep respirations.
Barrel chest.
Clubbing of the fingers.
Correct Answer : B,D,E
Choice A rationale
Bradycardia is not a typical assessment finding for a client with emphysema. Instead, these clients often experience tachycardia as a compensatory mechanism for chronic hypoxia. The heart rate increases to pump oxygenated blood more quickly to the tissues in response to decreased gas exchange efficiency in the alveoli. Therefore, a slow heart rate would be unexpected unless the client has a coexisting cardiac conduction disorder or is taking certain medications like beta-blockers.
Choice B rationale
Dyspnea, or shortness of breath, is a hallmark symptom of emphysema due to the destruction of alveolar walls and the loss of elastic recoil in the lungs. This leads to air trapping and hyperinflation, making it difficult for the client to exhale fully and inhale fresh air. As the disease progresses, dyspnea occurs even at rest because the physiological dead space increases, significantly reducing the surface area available for effective gas exchange and oxygenation.
Choice C rationale
Deep respirations are generally not found in emphysema; rather, clients tend to have rapid, shallow breathing patterns. Because of the hyperinflation of the lungs and the flattened diaphragm, the chest cannot expand and contract effectively for deep breaths. Clients often use accessory muscles to assist with breathing and may adopt a tripod position to help move air. The inefficiency of the respiratory pump in emphysema prevents the client from achieving significant tidal volumes.
Choice D rationale
A barrel chest is a classic clinical sign of emphysema resulting from chronic air trapping in the alveoli. Over time, the lungs stay hyperinflated, which increases the anteroposterior diameter of the thorax relative to the lateral diameter. This anatomical change reflects the permanent overdistension of the air spaces distal to the terminal bronchioles. It is a physical manifestation of the long-term struggle to exhale against obstructed airways and lost lung elasticity.
Choice E rationale
Clubbing of the fingers is a clinical sign characterized by the bulbous enlargement of the distal phalanges and a loss of the normal angle at the nail bed. It is often associated with chronic hypoxemia, which occurs in advanced emphysema. The exact mechanism involves increased capillary growth and fibroblast activity in the fingertips in response to low systemic oxygen levels. Its presence indicates long-standing respiratory insufficiency and significant impairment in pulmonary gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Performing up to four passes is generally avoided because each suctioning event increases the risk of mucosal trauma, hypoxia, and cardiac arrhythmias. The standard nursing practice is to limit suctioning to a maximum of two or three passes per session. Frequent passes can deplete the functional residual capacity of the lungs and cause significant distress to the client. The nurse must allow for adequate recovery and reoxygenation between each pass to maintain physiological stability.
Choice B rationale
Limiting each suction pass to 25 seconds is dangerously long and can lead to severe hypoxemia and vagal stimulation. The evidence-based limit for applying suction is typically 10 to 15 seconds. Prolonged suctioning removes not only secretions but also the air the client needs for oxygenation. Monitoring the heart rate and oxygen saturation during the procedure is vital, and the nurse should immediately stop if the client shows signs of bradycardia or a significant drop in saturation.
Choice C rationale
Applying suction while advancing the catheter into the trachea is incorrect because it causes unnecessary trauma to the tracheal mucosa and increases the risk of hypoxia. The catheter should be inserted without suction until resistance is met or the client coughs. Suction should only be applied intermittently or continuously while withdrawing the catheter using a rotating motion. This technique ensures that secretions are removed effectively while minimizing damage to the delicate tissues lining the client's airway.
Choice D rationale
Preoxygenating the client with 100 percent oxygen is a critical safety step before performing nasotracheal suctioning. Suctioning inherently removes oxygen from the airway, which can lead to desaturation and cardiac complications. By providing extra oxygen for 30 to 60 seconds before the procedure, the nurse builds a reservoir that helps maintain the client's arterial oxygen levels during the brief period of apnea and suctioning. This practice significantly reduces the risk of procedure-induced hypoxemia and arrhythmias.
Correct Answer is D
Explanation
Choice A rationale
Nonrebreather masks are designed to deliver high concentrations of oxygen, typically ranging from 60 percent to 90 percent, at flow rates of 10 to 15 liters per minute. This makes them high-flow delivery systems rather than low-flow systems like nasal cannulas. Using them for low-flow purposes would be ineffective and potentially dangerous, as the high flow is necessary to keep the reservoir bag inflated and ensure the patient receives the intended high oxygen concentration.
Choice B rationale
A nonrebreather mask is a large, tight-fitting device that covers both the nose and mouth to maintain high oxygen concentrations. It must be removed for the client to eat or drink, which poses a risk for desaturation during meals. In clinical practice, a nurse might temporarily switch a client to a nasal cannula during mealtime if tolerated, but the mask itself cannot remain in place while the client is consuming food or liquids.
Choice C rationale
The reservoir bag of a nonrebreather mask should never completely collapse. It is designed to remain partially inflated (one-third to one-half full) during inhalation to provide a continuous source of high-concentration oxygen. If the bag collapses during exhalation or inhalation, it indicates that the oxygen flow rate is set too low or there is a leak. Proper function requires a flow rate high enough to keep the reservoir bag adequately filled at all times.
Choice D rationale
A snug fit is essential for a nonrebreather mask to function correctly as a high-concentration delivery system. The mask features one-way valves that prevent room air from entering during inhalation and prevent exhaled air from returning to the reservoir bag. If the mask is loose, room air will dilute the oxygen, significantly decreasing the inspired oxygen fraction. Proper positioning over the nose and mouth ensures the client receives the maximum prescribed therapeutic oxygen level.
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