What is the underlying rationale for why a nurse assesses a client with emphysema for clinical indicators of hypoxia?
Increased mucus production blocks the alveoli
Infections decrease ventilation
Lack of adequate surface area for aeration
Inflammation of the bronchioles decreases breathing capacity
The Correct Answer is C
A. Increased mucus production blocking the alveoli is incorrect. While mucus production can be an issue in COPD, it is more characteristic of chronic bronchitis rather than emphysema.
B. Infections decreasing ventilation is incorrect. Although infections can worsen emphysema symptoms, they are not the primary cause of chronic hypoxia in these clients.
C. Lack of adequate surface area for aeration is correct. Emphysema leads to alveolar destruction and loss of elasticity, reducing the surface area available for gas exchange, which causes chronic hypoxia.
D. Inflammation of the bronchioles decreasing breathing capacity is incorrect. While airway inflammation is seen in conditions like asthma and chronic bronchitis, emphysema is primarily characterized by alveolar damage rather than airway inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Intermittent claudication with pallor is typically associated with peripheral artery disease (PAD) rather than myocardial infarction.
B. Jugular vein distention and dependent edema are signs of right-sided heart failure, which may develop after an MI but are not classic acute MI symptoms.
C. Mid-epigastric pain and heartburn can sometimes be confused with MI symptoms, but heartburn alone is not diagnostic of an MI.
D. Diaphoresis and cool clammy skin are correct. These symptoms occur due to sympathetic nervous system activation in response to cardiac ischemia, leading to vasoconstriction, sweating, and signs of impending shock.
Correct Answer is C
Explanation
A. Immediately notify the provider . A rise in the water seal chamber with inspiration (tidaling) is a normal finding, indicating proper function of the chest drainage system. There is no need for immediate provider notification.
B. Clamp the chest tube near the water seal . Clamping the chest tube can lead to a tension pneumothorax by trapping air inside the pleural space. This action is only done temporarily for specific indications, such as assessing for an air leak or changing the drainage system.
C. Continue to monitor the client . Tidaling (fluctuation of water with inspiration and expiration) is expected in the water seal chamber. The nurse should continue to monitor for any sudden cessation of tidaling (which may indicate obstruction) or continuous bubbling (which may indicate an air leak).
D. Reposition the client toward the left side . Position changes do not affect normal tidaling in a functioning chest tube system. However, frequent repositioning is encouraged to promote lung expansion.
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