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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Tell me about it.” This response by the nurse would best facilitate communication because it acknowledges the client’s emotional state and invites the client to express their feelings.
It also shows empathy and respect for the client.
Choice A is wrong because it does not address the client’s emotional needs or encourage communication.
It also implies that the nurse is uncomfortable with the client’s crying and wants to avoid it. Choice B is wrong because it does not show empathy or support for the client.
It also indicates that the nurse is too busy or unwilling to listen to the client.
Choice D is wrong because it is too vague and does not acknowledge the client’s emotional state.
It also puts the burden on the client to come up with a solution for their problem.
Correct Answer is D
Explanation
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.
The client may or may not need to use the bedpan depending on their fluid intake and output.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.
The client may or may not need to vomit depending on their underlying condition.
Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.