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The nurse is caring for a client at risk for a respiratory infection.
Which of the following natural respiratory defense mechanisms help defend against infection? (Select all that apply).

Cilia lining the respiratory tract sweep debris upward in mucus to be swallowed.

The respiratory tract cools and dries the air being inhaled.

Cells in the respiratory tract secrete lysozymes that can destroy certain bacteria.

Macrophages engulf and destroy bacteria found in the alveoli.

High concentration of oxygen and carbon dioxide aid the defense mechanisms.

Answer and Explanation

Correct Answer : A,C,D

These are natural respiratory defense mechanisms that help defend against infection.

Choice A is correct because cilia lining the respiratory tract sweep debris upward in mucus to be swallowed.

This prevents pathogens and particles from reaching the lungs.

Choice B is wrong because the respiratory tract does not cool and dry the air being inhaled. In fact, the respiratory tract warms and humidifies the air to facilitate gas exchange.

Choice C is correct because cells in the respiratory tract secrete lysozymes that can destroy certain bacteria.

Lysozymes are enzymes that break down the cell walls of bacteria.

Choice D is correct because macrophages engulf and destroy bacteria found in the alveoli. Macrophages are a type of white blood cell that act as scavengers of foreign invaders.

Choice E is wrong because high concentrations of oxygen and carbon dioxide do not aid the defense mechanisms.

On the contrary, high levels of these gases can impair gas exchange and cause acid-base imbalance.

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Correct Answer is A

Explanation

Maintain trust and avoid behaviors that may increase agitation. This is the priority action because it is important for the nurse to attempt to de-escalate the client and maintain trust.

A. Ordering the client to go to their room and alerting security is not the priority action because it may increase agitation and does not maintain trust.

C. Telling the client to sit down or risk isolation and loss of privileges is not the priority action because it may increase agitation and does not maintain trust.

D. Sedating the client after collecting a lithium level is not the priority action because it does not address the immediate need to de-escalate the situation and maintain trust.

A. Fluoroscopy to identify location. B. Aspirate contents and measure the pH. C. Inject air and listen for gurgling sounds. D. Observe for bubbles after placing the end of the tube in a cup of water.

Correct Answer is B

Explanation

This is because the pH of gastric contents is acidic (less than 5.5) and can indicate that the tube is in the stomach. This method is predictive of the correct placement of a nasogastric tube.

Choice A is wrong because fluoroscopy is not the most reliable method to confirm the correct placement of a nasogastric tube. It is an imaging technique that uses X-rays to show the movement of the tube, but it is not always available or feasible.

Choice C is wrong because injecting air and listening for gurgling sounds is not a reliable method to confirm the correct placement of a nasogastric tube. It can cause false-positive results and does not differentiate between the stomach and the respiratory tract.

Choice D is wrong because observing for bubbles after placing the end of the tube in a cup of water is not a reliable method to confirm the correct placement of a nasogastric tube. It can also cause false-positive results and does not differentiate between the stomach and the respiratory tract.

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The nurse is caring for a client at risk for a respiratory infection. Which of the following natural respiratory defense mechanisms help defend against infection? (Select all that apply).

Nursing Test Bank

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The nurse is caring for a client at risk for a respiratory infection.
Which of the following natural respiratory defense mechanisms help defend against infection? (Select all that apply).