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. Continue with the assessment, looking for any other abnormal findings: This is the correct response. Tonsils in adults can have various appearances, and a granular appearance with deep crypts is within the range of normal. It's essential for the nurse to continue the assessment and observe for other signs or symptoms that might indicate an issue.

B. Refer the patient to a throat specialist: Referring the patient based solely on the appearance of the tonsils, especially if it's a normal variant, might be unnecessary and could cause undue concern for the patient. It's important to assess the patient comprehensively before considering a specialist referral.

C. No response is needed; this appearance is normal for the tonsils: This is the correct explanation. In adults, tonsils often appear granular with deep crypts, which is considered a normal variation. No further action is required regarding the tonsils.

D. Obtain a throat culture on the patient for possible streptococcal (strep) infection: Based on the description provided (involution, granular appearance, and deep crypts), there's no specific indication of a streptococcal infection. Conducting a throat culture should be based on the presence of specific symptoms and signs indicative of a streptococcal infection, such as sore throat, fever, and swollen tonsils with white patches, rather than just the appearance of the tonsils.

A. Use of accessory muscles B. Nail bed greater than 160 degrees C. Circumoral cyanosis D. Pursed lip breathing E. Anteroposterior-to-transverse diameter of 1:1

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

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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

The nurse is assessing the tonsils of an adult client. The nurse notices that the tonsils are involuted, granular in appearance, and has deep crypts. The nurse recognizes that which of the following is the correct response to these findings?

Correct Answer is A

Explanation

Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

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