Based on the patient’s respiratory assessment and history, which assessment finding would indicate a worsening of Maria’s respiratory status?

Respiratory rate decreases to 18 breaths per minute.

Oxygen saturation increases to 90% on 2 L oxygen via nasal cannula.

Increased use of accessory muscles for breathing.

Productive cough with yellowish sputum.

Answer and Explanation

The Correct Answer is C

Choice A reason: Respiratory rate dropping to 18 breaths/min may suggest improvement or fatigue, not worsening, in respiratory status. Normal range (12-20) makes this less alarming than signs of increased breathing effort.

Choice B reason: Oxygen saturation rising to 90% on 2 L indicates better oxygenation, not worsening. It reflects treatment response, improving gas exchange, so this finding contradicts a decline in respiratory status.

Choice C reason: Increased accessory muscle use signals worsening respiratory distress, as it compensates for airway resistance or fatigue. It reflects higher work of breathing, a critical sign of decompensation needing intervention.

Choice D reason: Productive cough with yellowish sputum suggests infection, not immediate worsening of respiratory mechanics. It’s a chronic sign, less urgent than accessory muscle use indicating acute respiratory effort escalation.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Aspirin prevents thrombosis in coronary disease, not a primary heart failure treatment. It reduces ischemic risk but doesn’t address fluid overload or cardiac workload, lacking direct symptom relief in heart failure management.

Choice B reason: Lisinopril, an ACE inhibitor, reduces afterload and preload by vasodilation, easing heart strain. It manages heart failure symptoms like dyspnea by improving cardiac output, a cornerstone therapy for pump dysfunction.

Choice C reason: Insulin Glargine controls diabetes, not heart failure symptoms. It manages glucose, indirectly benefiting cardiovascular health, but doesn’t relieve congestion or improve hemodynamics, making it irrelevant to direct symptom management.

Choice D reason: Furosemide, a diuretic, reduces fluid overload in heart failure, alleviating dyspnea and edema. It lowers preload by increasing urine output, directly targeting congestion, a key symptom, in evidence-based practice.

Choice E reason: Metoprolol, a beta-blocker, slows heart rate, reducing myocardial demand in heart failure. It improves ejection fraction and symptoms like fatigue, a standard therapy for stabilizing cardiac function long-term.

A. Potassium level of 4.8 mEq/L B. Episodes of dizziness and blurred vision C. Chest x-ray showing mild left ventricular hypertrophy D. Blood pressure of 168/98 mmHg

Correct Answer is B

Explanation

Choice A reason: Potassium of 4.8 mEq/L is within normal range (3.5-5.0 mEq/L), posing no immediate threat. Hyperkalemia risks arrhythmias, but this level doesn’t warrant urgent action, as it’s stable and unlikely to disrupt cardiac function acutely.

Choice B reason: Dizziness and blurred vision suggest cerebral hypoperfusion or stroke, potentially from hypertension or embolism. These neurologic symptoms demand immediate action to assess and treat, as they indicate acute risk to brain function or life.

Choice C reason: Mild left ventricular hypertrophy on x-ray reflects chronic hypertension adaptation, not an acute emergency. It’s a stable finding requiring management, but it doesn’t necessitate immediate intervention compared to symptomatic neurologic changes.

Choice D reason: Blood pressure of 168/98 mmHg is elevated (stage 2 hypertension), risking long-term damage. Without acute symptoms, it’s less urgent than dizziness and vision changes, which signal immediate compromise needing rapid response.

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Based on the patient’s respiratory assessment and history, which assessment finding would indicate a worsening of Maria’s respiratory status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is B

Explanation

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