The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?
Clear and equal breath sounds bilaterally
Oxygen saturation of 98% on room air
Cough producing clear, thin sputum
Visible use of accessory muscles during inhalation
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Auricle (Pinna):
The auricle, also known as the pinna, is the visible external part of the ear. It consists of movable cartilage and skin. When administering eardrops, pulling the auricle up and back helps to straighten the ear canal, allowing the drops to enter the ear effectively.
B. Mastoid Process:
The mastoid process is a bony prominence located behind the ear. It is not a part of the outer ear structure involved in administering eardrops.
C. Outer Meatus:
The outer meatus, also known as the external acoustic meatus or ear canal, is the tube-like structure leading from the auricle to the eardrum. It is the passage through which eardrops are administered. Pulling the auricle up and back helps to straighten the outer meatus for the proper administration of eardrops.
D. Concha:
The concha refers to the bowl-shaped depression next to the ear canal. While it is a part of the outer ear, pulling the concha is not a technique used for administering eardrops. The auricle, specifically, is manipulated to facilitate the process.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
The pacemaker of the heart is known as the sinoatrial (SA) node. The SA node is a specialized group of cells located in the right atrium of the heart. It generates electrical impulses that initiate each heartbeat and set the rhythm for the entire heart.
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