RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Chart the reading at 91%, this is normal for a COPD patient.

Place a non-rebreather on the patient with high ﬂow oxygen.

Call the doctor if the patient is declining.

Sit the patient up and have them breathe deep.

Answer and Explanation

The Correct Answer is D

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

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Correct Answer is D

Explanation

Stridor is a high-pitched, inspiratory sound that indicates partial obstruction of the upper airway. It is a common finding in newborns and can occur due to the presence of mucus, ﬂuid, or a small airway that has not yet fully developed. It is important to note that while stridor is an expected finding in newborns, it should still be assessed and monitored closely by healthcare professionals.

Bruits are abnormal sounds heard over blood vessels and are not related to breath sounds. Crackles are a series of brief, discontinuous, nonmusical sounds heard during inspiration or expiration, indicating ﬂuid in the lungs. Wheezing is a high-pitched, musical sound heard during expiration and can indicate the narrowing of the airways. These sounds are not typically expected in the breath sounds of a newborn.

A. Auscultate bilateral breath sounds. B. Obtain blood culture for tuberculosis. C. Request pulmonary function studies. D. Document the findings.

Correct Answer is A

Explanation

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

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RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?

Correct Answer is D

Explanation

The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Correct Answer is A

Explanation

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