When administering oxygen to clients with conditions such as emphysema, it is important for the nurse to remember that for these clients the

drive to breathe may be dependent on low levels of oxygen in the blood

respiratory rate may be increased a great part of the time

lung stretch receptors may fail to monitor the patterns of breathing

intercostal muscles contract during inspiration, but fail to relax during expiration

Answer and Explanation

The Correct Answer is A

A. Drive to breathe may be dependent on low levels of oxygen in the blood: Clients with emphysema may have chronically elevated CO₂ levels, which can blunt their central chemoreceptor response. As a result, their respiratory drive may rely more on peripheral chemoreceptors sensing low oxygen levels.

B. Respiratory rate may be increased a great part of the time: While some clients with emphysema may exhibit tachypnea during exertion or exacerbations, this is not a consistent or defining characteristic across all situations.

C. Lung stretch receptors may fail to monitor the patterns of breathing: Lung stretch receptors play a role in the Hering-Breuer reflex, but there is no evidence that they fail to function in emphysema. The issue in emphysema is gas trapping and reduced surface area for gas exchange, not receptor failure.

D. Intercostal muscles contract during inspiration, but fail to relax during expiration: The intercostal muscles assist with ventilation, particularly during increased respiratory effort. However, their relaxation in expiration is typically passive and not impaired in emphysema.

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Correct Answer is C

Explanation

A. Increased protein:While protein supports immune function, high-protein diet is not the priority in the acute phase of an upper respiratory infection. The client may also have decreased appetite, sore throat, or nasal congestion, making solid food difficult to consume.

B. Soft, bland diet:This may be suitable for gastrointestinal issues or during recovery from oral or throat surgery, but it is not specifically indicated for upper respiratory infections. It also doesn't provide adequate hydration, which is a key focus during respiratory illness.

C. Clear liquid:A clear liquid diet helps keep the client hydrated, soothes throat irritation, and is easier to tolerate during acute illness. Broths, juices, teas, and electrolyte fluids help thin mucus secretions and prevent dehydration, which supports symptom management and recovery.

D. The client should be held NPO until symptoms improve:There is no reason to keep a client with an upper respiratory infection NPO unless they are experiencing vomiting or altered consciousness. Doing so would risk dehydration and slow recovery.

A. administer an NSAID for discomfort B. assess the patient's 02 saturation C. check the MAR for an order for a mild sedative D. take the patient off of oral fluids

Correct Answer is B

Explanation

A. Administer an NSAID for discomfort:While fever and discomfort may contribute to restlessness, NSAIDs do not address the most urgent concern, which is potential hypoxia. Treating symptoms without first assessing respiratory function may delay appropriate intervention.

B. Assess the patient's O₂ saturation:Increasing restlessness and confusion in a pneumonia patient can be early signs of hypoxia, especially in older adults. Oxygen saturation should be evaluated immediately to determine if the patient needs supplemental oxygen or further respiratory support.

C. Check the MAR for an order for a mild sedative:Sedatives may worsen confusion and can depress respiratory drive, particularly in hypoxic patients. Administering a sedative without first ruling out hypoxia may pose significant risk.

D. Take the patient off of oral fluids:Unless there are clear signs of aspiration or decreased level of consciousness, discontinuing oral fluids is not an appropriate first step. Hydration is important in pneumonia to help thin secretions and support recovery.

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When administering oxygen to clients with conditions such as emphysema, it is important for the nurse to remember that for these clients the

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Naxlex Comprehensive Predictor Exams

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