During a respiratory assessment, a nurse observes that a patient has labored breathing and is using accessory muscles. What does this suggest about the patient's respiratory system?
The patient is experiencing an obstruction in the lower airway.
The patient has adequate alveolar ventilation.
The patient has normal respiratory effort.
The patient is compensating for impaired gas exchange.
The Correct Answer is D
A. Obstruction in the lower airway: While possible, accessory muscle use is a general sign of increased work of breathing, not specific only to lower airway obstructions.
B. Adequate alveolar ventilation: Labored breathing suggests that ventilation is inadequate or under severe strain.
C. Normal respiratory effort: Normal breathing (eupnea) is quiet and uses only the diaphragm and external intercostals, not accessory muscles like the sternocleidomastoid.
D. The patient is compensating for impaired gas exchange: The body uses accessory muscles to increase the volume of the thoracic cavity to move more air when gas exchange is insufficient to meet metabolic demands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Insulin secretion: Insulin regulates blood glucose and can shift potassium into cells, but it doesn't regulate total body sodium.
B. Parathyroid hormone secretion: PTH regulates calcium and phosphorus levels.
C. Cortisol release: While cortisol has some mineralocorticoid effects, it is primarily a stress hormone regulating glucose and inflammation.
D. Aldosterone secretion: Aldosterone (from the adrenal cortex) acts directly on the kidneys to reabsorb sodium and water while excreting potassium.
Correct Answer is A
Explanation
A. Thickening of the alveolar-capillary membrane: Interstitial lung disease (ILD) involves inflammation and scarring (fibrosis) of the lung tissue. This physically thickens the barrier that oxygen must cross to enter the blood, significantly impairing diffusion.
B. Increased alveolar ventilation: Increased ventilation is typically a compensatory mechanism to combat hypoxemia, not the cause of the impaired gas exchange itself.
C. Enhanced capillary perfusion: Perfusion refers to blood flow. In ILD, perfusion is often mismatched or decreased due to structural damage; it is not "enhanced" in a way that would cause hypoxemic distress.
D. Decreased diffusion capacity of CO2: While CO2 diffusion can be affected, CO2 is much more soluble than oxygen. Hypoxemia in ILD is primarily due to the failure of oxygen to diffuse across the thickened membrane.
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