A nurse is caring for a client with acute pulmonary edema. Which mechanism is responsible for the accumulation of fluid in the alveoli and interstitial spaces in this condition?
Increased hydrostatic pressure in pulmonary capillaries
Decreased capillary permeability in the lungs
Enhanced lymphatic drainage from the lungs
Elevated colloid osmotic pressure in pulmonary vessels
The Correct Answer is A
A) Correct. Increased hydrostatic pressure in pulmonary capillaries, often due to left ventricular failure, leads to the filtration of fluid from the capillaries into the alveoli and interstitial spaces, causing pulmonary edema.
B) Incorrect. Decreased capillary permeability is not typically a primary factor in the development of pulmonary edema.
C) Incorrect. Enhanced lymphatic drainage from the lungs is not a primary mechanism responsible for the accumulation of fluid in pulmonary edema.
D) Incorrect. Elevated colloid osmotic pressure in pulmonary vessels would oppose fluid accumulation in the alveoli and is not a primary cause of pulmonary edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Skin temperature and color can provide important clues about tissue perfusion and oxygenation, which are critical in pulmonary edema.
B) Incorrect. While urinary output is important, it is not the primary focus when monitoring respiratory status in pulmonary edema.
C) Incorrect. Bowel sounds are unrelated to pulmonary edema and should not be the priority assessment.
D) Incorrect. Peripheral edema may be a sign of fluid retention, but skin color and temperature are more directly related to respiratory status.
Correct Answer is B
Explanation
A) Incorrect. The supine position with legs elevated is not recommended for clients with pulmonary edema, as it can worsen fluid retention.
B) Correct. High Fowler's position allows for optimal lung expansion and improved gas exchange in clients with pulmonary edema.
C) Incorrect. The left lateral recumbent position may be used in some cases, but it is not the primary position for managing pulmonary edema.
D) Incorrect. The prone position is not typically recommended for clients with pulmonary edema.
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