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 ["C","D","E"]
Explanation
A. Assessing level of consciousness is a nursing responsibility and cannot be delegated to the UAP.
B. Auscultating breath sounds requires clinical judgment and must be performed by a nurse.
C. Encouraging deep breathing exercises is within the scope of a UAP and can help improve gas exchange.
D. Recording a pulse oximeter reading is a task that can be delegated to a UAP, though interpretation remains the nurse’s responsibility.
E. Keeping the head of the bed elevated helps improve oxygenation and can be done by the UAP.
Correct Answer is C
Explanation
A. Encouraging increased fluid intake is incorrect. Clients with heart failure are at risk for fluid overload, and excessive fluid intake can worsen symptoms.
B. Simply monitoring and documenting findings is insufficient. A 2-pound weight gain in a short period suggests fluid retention and worsening heart failure, requiring further assessment and possible intervention.
C. Performing a head-to-toe assessment, including vital signs, is correct. The nurse should assess for worsening heart failure, including lung sounds (crackles), respiratory effort, blood pressure, and oxygen saturation, to determine if immediate interventions are needed.
D. Checking code status is not the priority. While knowing a client’s code status is important, the immediate concern is assessing for signs of fluid overload and potential decompensation.
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