The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?
Self-care deficit.
Activity intolerance.
Impaired gas exchange.
Ineffective airway clearance.
The Correct Answer is C
Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of lung tissue and loss of elasticity in the alveoli. This leads to poor gas exchange, specifically the reduced ability of oxygen to enter the bloodstream and carbon dioxide to be eliminated from the body. Impaired gas exchange can result in hypoxemia and hypercapnia, leading to symptoms such as shortness of breath, fatigue, and decreased exercise tolerance.
While self-care deficit, activity intolerance, and ineffective airway clearance are all potential complications associated with emphysema, impaired gas exchange is the priority due to its direct impact on the client's oxygenation and overall respiratory function.
Addressing impaired gas exchange and optimizing oxygenation is essential to support the client's respiratory health and prevent further complications. Management strategies for impaired gas exchange may include administering supplemental oxygen, implementing respiratory treatments to improve lung function, and providing education on breathing techniques and energy conservation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- As a nurse, it's important to provide accurate and helpful information to patients and families. In this situation, the parents have brought literature from a genetic counselor and are seeking clarification. The nurse should review the literature to the best of their ability and answer any questions they can. This approach demonstrates support, a willingness to help, and a commitment to providing accurate information.
B) Incorrect- While understanding the parents' reasons for seeking genetic counseling is important, it shouldn't be the first response when they have already brought literature and are seeking clarification. Addressing their questions and concerns is the immediate priority.
C) Incorrect- While it's true that the couple could contact the genetic counselor for further information, as a healthcare professional, the nurse should still offer assistance by reviewing the literature and answering questions to the best of their ability.
D) Incorrect- While support groups can be beneficial for parents of children with Trisomy 21, the immediate concern is addressing the parents' questions about the literature they've brought. Providing accurate information should be the primary focus at this time.
Correct Answer is ["B","C","D","G","H"]
Explanation
- Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
- Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
- Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
- Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
- Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
- Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.
Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.
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