When performing data collection for an aging patient with chronic respiratory symptoms, which finding would suggest impaired mucociliary function?
Decreased chest expansion during inhalation
Inspiratory wheezing
Clubbing of fingers
Chronic cough with sputum production
The Correct Answer is D
A. Decreased chest expansion during inhalation: This finding is more indicative of musculoskeletal stiffness, pain, or restrictive lung disease rather than a failure of the mucociliary escalator. While it affects ventilation, it does not directly reflect the status of the cilia or mucus transport. It is a measure of thoracic compliance.
B. Inspiratory wheezing: Wheezing indicates airway narrowing, which can be caused by various factors including bronchospasm or inflammation. While mucus can narrow the airway, wheezing is not the most specific indicator of impaired ciliary function. It is a sign of obstruction rather than a specific failure of clearance.
C. Clubbing of fingers: Clubbing is a sign of chronic systemic hypoxemia and is common in long-standing conditions like bronchiectasis or lung cancer. It reflects the duration of the disease rather than the acute functional status of the mucociliary system. It is a late-stage physical finding of chronic respiratory distress.
D. Chronic cough with sputum production: The mucociliary escalator is responsible for moving trapped particles and mucus up and out of the lungs. When this system fails, secretions accumulate in the airways, necessitating a cough to clear the debris. A productive cough is the clinical consequence of ineffective ciliary transport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased sputum viscosity:Higher thickness of bronchial secretions makes expectoration more difficult and increases the likelihood of airway obstruction. It indicates a worsening of the patient's ability to clear the tracheobronchial tree effectively. This finding is often associated with dehydration or advancing pulmonary pathology.
B. Decreased lung crackles:The reduction of adventitious sounds indicates that secretions are being cleared from the smaller airways and alveoli. This signifies improved ventilation and a return to normal laminar airflow within the bronchopulmonary segments. It reflects successful clearance of obstructive exudates or fluids.
C. Increased body temperature:Pyrexia typically suggests an active inflammatory or infectious process such as pneumonia. Elevated metabolic rates associated with fever can increase oxygen demand and complicate respiratory distress. It does not provide evidence that the physical obstruction of the airway has been resolved.
D. Evidence of cyanosis:A bluish discoloration of the skin indicates severe hypoxemia and inadequate gas exchange. It is a late sign of respiratory failure and confirms that the airway or alveolar ventilation is critically compromised. This finding suggests a decline in clinical status rather than improvement.
Correct Answer is A
Explanation
A. Infusing isotonic intravenous fluids: Severe dehydration indicates a critical loss of intravascular volume that can lead to hypovolemic shock and organ failure. Isotonic fluids, such as 0.9% normal saline or lactated Ringer’s, expand the extracellular fluid volume without causing significant cellular shifts. This is the fastest method to restore perfusion in a patient.
B. Administering oral rehydration salts: While oral rehydration is highly effective for mild to moderate dehydration, it is often insufficient for severe cases where the patient may have an altered level of consciousness or impaired gastric absorption. Intravenous access is necessary to bypass the digestive system. Rapid volume expansion is required to prevent circulatory collapse.
C. Encouraging increased water intake: Oral water intake is a preventative or maintenance measure for healthy individuals or those with minimal fluid loss. In the context of severe dehydration, the patient's thirst mechanism and oral capacity cannot keep pace with the urgent need for volume. It is not an appropriate primary intervention for acute medical stabilization.
D. Monitoring daily weights: Tracking weight is an essential nursing intervention for monitoring fluid trends over time, particularly in chronic conditions like renal or heart failure. However, in an acute dehydration crisis, it is a diagnostic or evaluative tool rather than a therapeutic one. The immediate priority is active fluid replacement.
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