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 ["B","D","E"]
Explanation
Choice A rationale: Hypernatremia involves elevated sodium levels, so encouraging potassium-rich foods is not directly related to addressing hypernatremia.
Choice B rationale: Restricting sodium in the diet is appropriate to help manage and reduce hypernatremia. This can prevent further complications of hypernatremia, such as dehydration, confusion, seizures, and coma.
Choice C rationale: This is not an appropriate intervention for hypernatremia, as water intake can help dilute the sodium levels and restore the fluid balance in the body.
Decreasing water intake can worsen the hypernatremia and cause dehydration. Choice D rationale: This is an appropriate intervention for hypernatremia, as high sodium levels can affect the fluid balance and blood pressure in the body. Monitoring
vital signs can help detect any changes or abnormalities that may indicate worsening of the condition or need for further treatment.
Choice E rationale: Monitoring intake and output helps assess fluid balance and response to interventions for hypernatremia.
Correct Answer is B
Explanation
Choice A rationale: Reading previous documentation provides historical information but may not reflect the current level of dyspnea.
Choice B rationale: Observing the client at rest and during activity is the best way to assess the current level of dyspnea.
Choice C rationale: Asking if shortness of breath is being experienced provides subjective information but may not be as reliable as direct observation.
Choice D rationale: Auscultating lung sounds is important for assessing respiratory function but may not provide a comprehensive picture of dyspnea.
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