The nurse understands that the major factor affecting oxygenation in a client who has fluid in the lungs is:
poor tissue perfusion from circulatory insufficiency.
decreased diffusion of oxygen from the alveoli to the blood.
lowered oxygen carrying capacity.
decreased concentration of oxygen in the air.
The Correct Answer is B
Choice A rationale: Poor tissue perfusion from circulatory insufficiency can affect oxygenation, but fluid in the lungs primarily impacts gas exchange at the alveolar level.
Choice B rationale: Decreased diffusion of oxygen from the alveoli to the blood is a major factor affecting oxygenation when fluid is present in the lungs.
Choice C rationale: Lowered oxygen carrying capacity can affect oxygenation but is not the primary concern in the presence of fluid in the lungs.
Choice D rationale: Decreased concentration of oxygen in the air is not the primary factor affecting oxygenation in a client with fluid in the lungs.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Maintaining continuous oxygen therapy does not directly address the thinning of respiratory secretions.
Choice B rationale: Maintaining a consistent air temperature in the client's room is not directly related to thinning respiratory secretions.
Choice C rationale: Keeping the client in a supine position as much as possible is not the most helpful action for thinning respiratory secretions.
Choice D rationale: Assisting the client to maintain an adequate fluid intake is the most helpful action in thinning respiratory secretions, promoting hydration and mobilization of secretions.
Correct Answer is C
Explanation
Choice A rationale: Heat therapy is generally contraindicated for a wound that is bleeding, as it can increase bleeding.
Choice B rationale: Heat therapy may not be appropriate for a client with impaired sensation due to the risk of burns.
Choice C rationale: The client who is experiencing spasms of the calf muscles can benefit from heat therapy, which can help relax the muscles and reduce pain. Heat therapy increases blood flow and oxygen delivery to the affected area, which promotes healing and reduces inflammation.
Choice D rationale: Heat therapy is contraindicated for the client who has an active, localized inflammation (D), because heat can worsen the inflammation and increase the risk of infection.
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