The nurse is doing an assessment of an adult client and noticed unequal chest expansion. The nurse recognizes that unequal chest expansion occurs:

When part of the lung is obstructed or collapsed

When bulging of the intercostal spaces is present

In an obese patient

When accessory muscles are used to augment respiratory effort

Answer and Explanation

The Correct Answer is A

A. When part of the lung is obstructed or collapsed: This statement is accurate. Unequal chest expansion can occur when part of the lung is obstructed or collapsed, preventing the affected area from expanding normally during inhalation.

B. When bulging of the intercostal spaces is present: This statement is not accurate. Unequal chest expansion typically refers to decreased expansion on one side, not bulging of intercostal spaces.

C. In an obese patient: This statement is not accurate. Obesity can affect breathing patterns and lung function, but it is not the primary cause of unequal chest expansion.

D. When accessory muscles are used to augment respiratory effort: This statement is not accurate. The use of accessory muscles to augment respiratory effort can be a sign of respiratory distress, but it doesn't directly cause unequal chest expansion. Unequal expansion is more indicative of specific lung conditions or issues with lung mechanics.

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Correct Answer is D

Explanation

A. Clear and equal breath sounds bilaterally

Explanation: Clear and equal breath sounds bilaterally indicate normal lung sounds, suggesting proper air exchange in both lungs. This is a normal finding and does not require immediate reporting.

B. Oxygen saturation of 98% on room air

Explanation: An oxygen saturation level of 98% on room air indicates adequate oxygenation of the blood. This is a normal and healthy oxygen saturation level and does not require immediate reporting.

C. Cough producing clear, thin sputum

Explanation: A cough producing clear, thin sputum is indicative of a non-infected or non-inflammatory condition in the respiratory system. Clear and thin sputum is often normal, especially in the absence of other symptoms. It does not require immediate reporting unless the client has other concerning symptoms.

D. Visible use of accessory muscles during inhalation

Explanation: Visible use of accessory muscles, such as neck or intercostal muscles, during inhalation suggests that the client is working hard to breathe. This could indicate respiratory distress, potentially due to conditions like asthma, COPD (Chronic Obstructive Pulmonary Disease), or other severe lung problems. It's a concerning sign and should be reported to the healthcare practitioner promptly for further evaluation and intervention.

A. indicates turbulent blood flow through a valve. B. is an extra sound due to blood entering an inflexible chamber. C. means that there is some inflammation around the heart. D. is a high-pitched sound due to a narrow valve.

Correct Answer is A

Explanation

A. Indicates turbulent blood flow through a valve:

This statement is correct. A heart murmur is an abnormal sound during the heartbeat cycle, often indicating turbulent blood flow through a valve. Murmurs can result from various factors such as valve disorders, structural abnormalities, or other heart conditions.

B. Is an extra sound due to blood entering an inflexible chamber:

This statement is not accurate. Heart murmurs are primarily associated with turbulent blood flow rather than an extra sound related to an inflexible chamber.

C. Means that there is some inflammation around the heart:

This statement is incorrect. Heart murmurs are not specifically related to inflammation around the heart. They are primarily caused by issues with blood flow through the heart valves.

D. Is a high-pitched sound due to a narrow valve:

This statement is a bit oversimplified. While murmurs can sometimes be associated with narrow valves (stenosis), they can also result from various other valve abnormalities or conditions, and not all murmurs are high-pitched. The pitch and characteristics of a murmur can provide clues about its cause, but they are not the sole indicators.

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The nurse is doing an assessment of an adult client and noticed unequal chest expansion. The nurse recognizes that unequal chest expansion occurs:

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Naxlex Comprehensive Predictor Exams

The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?

Correct Answer is D

Explanation

A client was recently diagnosed with a heart murmur and is asking the nurse for more information. The nurse will educate the client that a heart murmur:

Correct Answer is A

Explanation

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