To promote the release of surfactant, the nurse encourages the patient to:

Take deep breaths.

Cough five times per hour to prevent alveolar collapse.

Decrease fluid intake to reduce fluid accumulation in the alveoli.

Sit with head of bed elevated to promote air movement through the pores of Kohn.

Answer and Explanation

The Correct Answer is A

To promote the release of surfactant, the nurse should encourage the patient to take deep breaths. Deep inspiration stretches the alveoli, stimulating type II alveolar cells to produce and secrete surfactant, which reduces surface tension and prevents alveolar collapse, thereby improving gas exchange and lung compliance.

Rationale for correct answer:
1. Take deep breaths. Deep breathing increases alveolar expansion, which triggers the production and release of pulmonary surfactant. Surfactant coats the alveolar surfaces, reducing surface tension and helping to keep alveoli open during exhalation. This mechanism is especially important for preventing atelectasis (alveolar collapse) and maintaining effective ventilation-perfusion balance.

Rationale for incorrect answers:
2. Cough five times per hour to prevent alveolar collapse. While coughing helps clear secretions and promote airway patency, it does not directly stimulate surfactant production. Deep breathing, not coughing, is the physiologic action that enhances surfactant release by expanding the alveoli.
3. Decrease fluid intake to reduce fluid accumulation in the alveoli. Limiting fluid intake does not influence surfactant production and could even lead to dehydration, thickened secretions, and impaired airway clearance. Surfactant release depends on alveolar expansion, not fluid restriction.
4. Sit with head of bed elevated to promote air movement through the pores of Kohn. Elevating the head of the bed aids ventilation but does not directly stimulate surfactant release. The pores of Kohn allow for collateral air movement between alveoli, but this process is not affected by patient positioning alone.

Take-home points:

Deep breathing enhances surfactant release, maintaining alveolar stability and improving oxygenation.
Coughing and positioning aid airway clearance but do not replace the benefits of alveolar expansion.
Encouraging incentive spirometry or deep breathing exercises is vital for preventing atelectasis in postoperative and immobile patients.

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Correct Answer is C

Explanation

A patient’s respiratory rate increases when there is an excess of carbon dioxide in the blood because CO₂ combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid (CSF). This acidic change stimulates the central chemoreceptors in the medulla oblongata, which respond by increasing the rate and depth of respiration to expel excess CO₂ and restore normal pH balance.

Rationale for correct answer:
3. CO₂ combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. When CO₂ levels rise in the blood (hypercapnia), it diffuses across the blood–brain barrier and reacts with water to form carbonic acid (H₂CO₃). The acid dissociates into hydrogen ions (H⁺), decreasing CSF pH. This stimulates central chemoreceptors in the medulla, triggering an increase in respiratory rate and tidal volume to eliminate excess CO₂ and maintain acid–base balance.

Rationale for incorrect answers:
1. CO₂ displaces oxygen on hemoglobin, leading to decreased PaO₂. While CO₂ can bind to hemoglobin, it does not directly displace oxygen to the extent that it causes increased respiratory drive; the primary mechanism involves pH changes in CSF.
2. CO₂ causes an increase in the amount of hydrogen ions available in the body. Although this is true, it is incomplete — the lowered CSF pH, not simply the presence of hydrogen ions, is what stimulates the respiratory center.
4. CO₂ directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. CO₂ itself is not the direct stimulant; rather, the acidic pH resulting from CO₂ conversion to carbonic acid activates the chemoreceptors.

Take-home points:

Excess CO₂ leads to the formation of carbonic acid, lowering CSF pH.
Central chemoreceptors in the medulla detect this pH drop and increase respiration.
The body compensates by expelling CO₂, restoring pH homeostasis.
The respiratory drive is primarily controlled by CO₂ levels and CSF pH, not oxygen concentration.

A. Nail polish B. Inadequate peripheral circulation C. Hyperthermia D. Increased hemoglobin (Hgb) level E. Edema

Correct Answer is ["A","B","E"]

Explanation

A low pulse oximetry reading may occur due to factors that interfere with accurate detection of oxygen saturation, such as nail polish, inadequate peripheral circulation, and edema. These conditions can prevent the oximeter’s light sensor from properly detecting arterial oxygen levels, leading to falsely low readings even when the patient’s oxygenation is normal.

Rationale for correct answers:
1. Nail polish. Dark-colored nail polish or artificial nails can block or distort the light signal used by the pulse oximeter, resulting in inaccurate or falsely low readings. The nurse should remove nail polish or use an alternate sensor site, such as the earlobe or toe, to obtain a reliable measurement.

2. Inadequate peripheral circulation. Poor blood flow, as seen in hypotension, hypothermia, or peripheral vascular disease, reduces the pulsatile flow required for accurate pulse oximetry readings. This can cause the device to register a lower saturation level than the actual arterial oxygen concentration.

5. Edema. Tissue swelling, especially in the fingers, interferes with the light transmission and absorption used by the oximeter. This results in unreliable or falsely low readings because the sensor cannot effectively detect the pulsating arterial blood.

Rationale for incorrect answers:
3. Hyperthermia. Elevated body temperature typically increases peripheral circulation and does not contribute to a low oxygen saturation reading. In some cases, it may even improve signal accuracy.
4. Increased hemoglobin (Hgb) level. A higher hemoglobin concentration enhances the blood’s oxygen-carrying capacity and does not lower pulse oximetry readings. In fact, pulse oximetry measures the percentage of hemoglobin saturated with oxygen, not the total hemoglobin level.

Take-home points:

Nail polish, poor circulation, and edema can lead to falsely low pulse oximetry readings.
Always verify low readings by reassessing with a clean, well-perfused site or using arterial blood gases (ABGs) for accuracy.
Pulse oximetry readings should always be interpreted in conjunction with the patient’s overall clinical presentation.

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To promote the release of surfactant, the nurse encourages the patient to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Why does a patient’s respiratory rate increase when there is an excess of carbon dioxide in the blood?

Correct Answer is C

Explanation

A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient?

Which assessment finding of the respiratory system does the nurse interpret as abnormal?

The nurse is giving instructions to a client having pulmonary angiography. Which of the following statements is the best evidence that the client understands what will take place during the diagnostic procedure? (Select all that apply.)

A patient’s ABGs include PaO2 88 mm Hg and PaCO2 38 mm Hg; mixed venous gases include PvO2 40 mm Hg and PvCO2 46 mm Hg. What do these findings indicate?

Palpation is the assessment technique used to find which abnormal findings? (Select all that apply.)

A nurse has been exposed to tuberculosis (TB) during care of a patient with TB and has a TB skin test performed. When is the nurse considered infected?

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test?

Which respiratory defense mechanism is most impaired by smoking?