Patient Data
Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings
Rhonchi in the right lung
Symmetric chest expansion
Oxygen saturation greater than 949%
PaCO2 55 mm Hg on a blood gas
Client ambulates without shortness of breath
Diminished breath sounds in the right lung
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
A. Rhonchi are abnormal breath sounds that indicate the presence of mucus or fluid in the airways. Finding rhonchi in the right lung suggests the presence of respiratory congestion or obstruction, which may indicate ineffective treatment or ongoing respiratory issues.
B. Symmetric chest expansion indicates equal and adequate movement of both sides of the chest during inhalation. This finding suggests that there are no restrictions or abnormalities in the chest wall or lung tissue, which is indicative of effective treatment.
C. Oxygen saturation greater than 94% indicates adequate oxygenation of the blood, which is a positive indicator of effective treatment, particularly in clients with respiratory issues such as pneumonia or COPD.
D. A PaCO2 level of 55 mm Hg indicates hypercapnia, which is an elevated level of carbon dioxide in the blood. This finding suggests inadequate ventilation or respiratory failure, indicating ineffective treatment.
E. The ability to ambulate without experiencing shortness of breath suggests improved respiratory function and effective treatment, as it indicates adequate oxygenation and ventilation.
F. Diminished breath sounds suggest reduced airflow or lung volume in the affected area. This finding may indicate ongoing respiratory issues or incomplete resolution of the condition, suggesting ineffective treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Aspiration can lead to serious respiratory complications such as pneumonia. Since the client reports difficulty swallowing (dysphagia) and has a high pain level, addressing the risk for aspiration is crucial to prevent further complications.
A. While nutrition is essential for overall health, it may not be the priority in this case given the severity of other symptoms such as pain, dysphagia, and anxiety.
C. Esophageal cancer can cause significant pain due to tissue destruction by the tumor, which can affect the client's quality of life and ability to function. This however, should be addressed after immediate concerns in the ABCs.
D. While addressing the client's emotional needs is important for holistic care, it may not be the immediate priority compared to managing symptoms such as pain and dysphagia,
Correct Answer is A
Explanation
Hydromorphone is an opioid analgesic that can cause constipation as a side effect by slowing down gastrointestinal motility. Prolonged use of opioids, such as hydromorphone, increases the risk of developing opioid-induced constipation (OIC), which can lead to discomfort, bowel obstruction, and other complications if left untreated.
B. Edema is not typically associated with hydromorphone use, especially when administered for a short duration.
C. Hydromorphone administration is not typically associated with significant alterations in heart rate or rhythm, especially when administered at appropriate doses.
D. hydromorphone administration is not typically associated with alterations in blood glucose levels. Therefore, assessing capillary glucose levels may not be the most relevant assessment in this scenario.
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