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The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Draw air in through the nose and exhale slowly through pursed lips.

Lay down on each side with knees bent and breathe from the abdomen.

Increase breathing rate for a full 30 seconds.

Raise hands above the head to expand the diaphragm.

Answer and Explanation

The Correct Answer is A

Rationale for Choice A:

Pursed-lip breathing:

Creates back pressure in the airways, which helps to keep them open longer during exhalation.

Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.

Promotes relaxation and reduces anxiety, which can also help to improve breathing.

Rationale for Choice B:

Side-lying position with knees bent:

May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.

May not be comfortable for all clients.

Rationale for Choice C:

Increasing breathing rate:

Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.

Rationale for Choice D:

Raising hands above the head:

Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.

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Correct Answer is A

Explanation

Choice A rationale:

Pneumonia is the most likely diagnosis given the rapid development of pulmonary infiltrates within a 24-hour period. Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi. It typically presents with symptoms such as fever, cough, shortness of breath, and chest pain. The presence of pulmonary infiltrates on imaging studies, such as a chest X-ray, is a key diagnostic feature of pneumonia.

The distribution of the infiltrates, involving the lower lobes with a predominance on the right side, is also consistent with pneumonia. This is because the lower lobes are more susceptible to pneumonia due to their anatomy and gravity.

The absence of active processes on Day 1 makes other diagnoses less likely. For example, tuberculosis typically develops more slowly over weeks or months, and bronchitis usually does not cause pulmonary infiltrates.

Pulmonary embolism can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.

Choice B rationale:

Tuberculosis is a chronic infection that typically develops slowly over weeks or months. It is less likely to cause rapid development of pulmonary infiltrates as seen in this case.

Tuberculosis often involves the upper lobes of the lungs, and it may be associated with other symptoms such as fever, night sweats, and weight loss.

Choice C rationale:

Bronchitis is an inflammation of the bronchi, the large airways that carry air to the lungs. It typically causes a cough, but it does not usually cause pulmonary infiltrates.

Bronchitis is often caused by a virus, and it usually resolves on its own within a few weeks.

Choice D rationale:

Pulmonary embolism is a blockage of a pulmonary artery, one of the blood vessels that carries blood to the lungs. It can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.

Pulmonary embolism is often caused by a blood clot that travels from a vein in the leg to the lungs.

A. Autoimmune response. B. Type II hypersensitivity. C. Cell-mediated hypersensitivity. D. IgE response hypersensitivity.

Correct Answer is D

Explanation

Choice A rationale:

Autoimmune responses occur when the immune system mistakenly attacks the body's own tissues. They are not typically triggered by allergens like bee stings.

Autoimmune responses often develop slowly over time and present with symptoms related to the specific tissues being attacked.

The rapid onset of symptoms in this case, along with the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of an autoimmune response.

Choice B rationale:

Type II hypersensitivity reactions involve antibodies that target and destroy cells or tissues. These reactions often take hours or days to develop, rather than minutes.

Examples of type II hypersensitivity reactions include transfusion reactions, hemolytic disease of the newborn, and some autoimmune diseases.

The rapid onset of symptoms in this case is not consistent with a type II hypersensitivity reaction.

Choice C rationale:

Cell-mediated hypersensitivity reactions involve T cells that directly attack cells or tissues. These reactions typically take 1-3 days to develop.

Examples of cell-mediated hypersensitivity reactions include contact dermatitis (e.g., poison ivy), graft-versus-host disease, and some drug reactions.

The rapid onset of symptoms in this case, as well as the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of a cell-mediated hypersensitivity reaction.

Choice D rationale:

IgE response hypersensitivity reactions are the most immediate type of allergic reaction.

They are mediated by immunoglobulin E (IgE) antibodies, which bind to mast cells and basophils.

When an allergen (like bee venom) cross-links IgE antibodies on mast cells, it triggers the release of histamine and other inflammatory mediators.

These mediators cause vasodilation, increased vascular permeability, smooth muscle contraction, and mucus secretion, leading to the characteristic symptoms of an allergic reaction.

The rapid onset of symptoms in this case, including rash, shortness of breath, and low blood pressure, are consistent with an IgE-mediated hypersensitivity reaction.

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The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is D

Explanation

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