The nurse is caring for a client at risk for a respiratory infection.
Which of the following natural respiratory defense mechanisms help defend against infection? (Select all that apply).
Cilia lining the respiratory tract sweep debris upward in mucus to be swallowed.
The respiratory tract cools and dries the air being inhaled.
Cells in the respiratory tract secrete lysozymes that can destroy certain bacteria.
Macrophages engulf and destroy bacteria found in the alveoli.
High concentration of oxygen and carbon dioxide aid the defense mechanisms.
Correct Answer : A,C,D
These are natural respiratory defense mechanisms that help defend against infection.
Choice A is correct because cilia lining the respiratory tract sweep debris upward in mucus to be swallowed.
This prevents pathogens and particles from reaching the lungs.
Choice B is wrong because the respiratory tract does not cool and dry the air being inhaled. In fact, the respiratory tract warms and humidifies the air to facilitate gas exchange.
Choice C is correct because cells in the respiratory tract secrete lysozymes that can destroy certain bacteria.
Lysozymes are enzymes that break down the cell walls of bacteria.
Choice D is correct because macrophages engulf and destroy bacteria found in the alveoli. Macrophages are a type of white blood cell that act as scavengers of foreign invaders.
Choice E is wrong because high concentrations of oxygen and carbon dioxide do not aid the defense mechanisms.
On the contrary, high levels of these gases can impair gas exchange and cause acid-base imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Correct Answer is B
Explanation
“I apologize for not hearing you say that. Is there a better day for you?”.
This response shows empathy and respect for the client’s feelings and preferences.
It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.
It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.
It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.
Choice D is wrong because it is persuasive and manipulative.
It does not address the client’s concerns or explore other options.
The nurse-client relationship is based on trust, respect, and collaboration.
The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.
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