What subjective data should the nurse obtain about a client's respiratory status? Select all that apply.

question the patient about shortness of breath

palpate the chest and back for masses

inspect the skin and nails for integrity and color

Ask the patient about color and quantity of sputum

auscultate for lung sounds anteriorly and posteriorly

Answer and Explanation

Correct Answer : A,D

A. Asking about shortness of breath is critical subjective data that indicates respiratory distress.
B. Palpating for masses is more of a physical assessment and does not yield subjective data.
C. Inspecting skin and nails is also part of the objective assessment rather than subjective data.
D. Inquiring about the color and quantity of sputum provides important subjective data related to respiratory function.
E. Auscultation is an objective assessment technique and does not pertain to subjective data.

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Correct Answer is A

Explanation

A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.

A. Pulse 60 B. Pulse 90 C. Oxygen saturation of 92% D. Oxygen saturation 89% E. Blood pressure 130/80

Correct Answer is D

Explanation

A. A pulse of 60 is low but does not necessarily indicate a need to stop suctioning if the patient remains stable otherwise.
B. A pulse of 90 is within normal limits and does not require stopping suctioning.
C. An oxygen saturation of 92% is slightly low but still acceptable; suctioning can continue if the client is stable.
D. An oxygen saturation of 89% is below the acceptable threshold and indicates hypoxia, prompting the nurse to stop suctioning immediately to avoid further compromising the client's respiratory status.
E. A blood pressure of 130/80 is within normal limits and does not warrant cessation of suctioning.

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What subjective data should the nurse obtain about a client's respiratory status? Select all that apply.

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Naxlex Comprehensive Predictor Exams

When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

Correct Answer is A

Explanation

A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

Correct Answer is D

Explanation

The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

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What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.