A middle-aged client reports, "I can't get my breath when I walk." Upon assessment, the nurse notes that the patient has a barrel chest and is using his accessory muscles to breathe. The patient's respiratory rate is 28/min. On palpation, there is limited expansion and decreased tactile fremitus. Percussion yields hyperresonant sounds. On auscultation, prolonged expiration, scattered wheezes, and rhonchi are present. Which disorder would the nurse suspect?
Pneumonia.
Atelectasis.
Pleural effusion.
Emphysema.
The Correct Answer is D
Choice A rationale:
Pneumonia is not likely to be the correct answer. Pneumonia is often characterized by productive cough, fever, chest pain, and increased tactile fremitus due to consolidation of lung tissue. The presence of barrel chest, decreased tactile fremitus, and hyperresonant percussion sounds is not consistent with pneumonia.
Choice B rationale:
Atelectasis is not the most likely option. Atelectasis refers to collapsed or partially collapsed lung tissue, which can lead to decreased breath sounds, dullness to percussion, and decreased tactile fremitus. The symptoms mentioned in the scenario, such as prolonged expiration, wheezes, and barrel chest, are not indicative of atelectasis.
Choice C rationale:
Pleural effusion is not the most suitable choice. Pleural effusion usually presents with decreased breath sounds, dullness to percussion, and decreased tactile fremitus over the affected area due to fluid accumulation in the pleural space. The hyperresonant percussion sounds and the presence of wheezes and rhonchi do not align with pleural effusion.
Choice D rationale:
Emphysema is the most likely disorder based on the given symptoms. Barrel chest (increased anterior-posterior chest diameter), limited lung expansion, decreased tactile fremitus, hyperresonant percussion sounds, prolonged expiration, wheezes, and rhonchi are characteristic findings of emphysema. This condition involves damage to the alveoli and their supporting structures, leading to air trapping, reduced lung elasticity, and obstructed airflow. The patient's use of accessory muscles to breathe further suggests a chronic obstructive pulmonary disease (COPD) like emphysema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Autonomy refers to a patient's right to make their own decisions about their medical care. While autonomy is an important ethical principle, it is not directly related to the situation described. The nurse providing oxygen therapy to the patient without the patient's consent is not an example of respecting autonomy.
Choice B rationale:
Beneficence is the correct choice. Beneficence is the ethical principle of doing what is best for the patient's well-being. In this situation, providing oxygen therapy to a patient experiencing difficulty in breathing aligns with the principle of beneficence. Oxygen therapy aims to improve the patient's oxygenation and alleviate respiratory distress.
Choice C rationale:
Veracity refers to truthfulness and honesty in communication. While honesty is important, it is not the primary ethical principle at play in this situation. Providing oxygen therapy to improve the patient's condition is more aligned with beneficence.
Choice D rationale:
Fidelity refers to the duty to be faithful and keep promises. While fidelity is important in maintaining trust between healthcare providers and patients, it is not the primary principle relevant here. The priority is to address the patient's immediate health needs through appropriate interventions like oxygen therapy.
Correct Answer is C
Explanation
Choice A rationale:
Admission assessment of a new client requires comprehensive evaluation, critical thinking, and clinical judgment. This task is within the scope of a registered nurse's responsibilities and should not be delegated to an LPN.
Choice B rationale:
Evaluating changes to a client's pressure ulcer also involves clinical judgment and assessment skills that fall within the domain of a registered nurse's role.
Choice C rationale:
This is the correct choice. Tracheostomy care involves routine and standardized procedures that an LPN can perform under the supervision of a registered nurse. LPNs are trained to provide this type of care safely and effectively.
Choice D rationale:
Administering a blood transfusion is a complex procedure that requires careful monitoring and assessment for potential adverse reactions. This task is typically within the scope of a registered nurse's practice, not an LPN's.
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