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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.

This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.

B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.

This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.

C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.

This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.

D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.

A. Nystagmus in extreme superior gaze B. Slight amount of lid lag when moving the eyes from a superior to an inferior position C. Parallel movement of both eyes D. Convergence of the eyes

Correct Answer is C

Explanation

A. Nystagmus in extreme superior gaze: Nystagmus is an involuntary eye movement and is not a normal finding, especially in extreme superior gaze. Nystagmus can be indicative of neurological issues and requires further evaluation.

B. Slight amount of lid lag when moving the eyes from a superior to an inferior position: Lid lag refers to a delay in the downward movement of the upper eyelid during eye movement. This can be a sign of hyperthyroidism and is not a normal finding.

C. Parallel movement of both eyes: This is the correct answer. During the diagnostic positions test, the nurse should observe parallel movement of both eyes in all directions, indicating normal extraocular muscle function and coordination.

D. Convergence of the eyes: Convergence refers to the inward movement of both eyes when focusing on a close object. While convergence is a normal phenomenon, it is not specifically assessed during the diagnostic positions test, which primarily evaluates the range of motion and coordination of the extraocular muscles.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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