Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?
Clubbing of the fingernails
Tracheal deviation
Contraction of the diaphragm
Auscultation of rhonchi throughout the lungs
The Correct Answer is B
A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client exhales as the medication is released from the inhaler: This is incorrect. The client should inhale deeply while activating the inhaler. Exhaling before inhaling will reduce the effectiveness of the medication.
B. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. The client should inhale slowly and deeply to allow the medication to reach the lungs effectively. A quick inhalation may result in less medication being delivered to the lungs.
C. The client holds his breath for 10 seconds after inhaling the medication: This is the correct action. Holding the breath allows the medication to settle in the lungs, enhancing its therapeutic effect.
D. The client waits 10 min between inhalations: This is not necessary unless instructed by the healthcare provider. Most guidelines suggest waiting 1 to 2 minutes between inhalations of the same medication.
Correct Answer is C
Explanation
A. Hepatitis B is a viral infection and is not typically a concern for asthma patients in terms of environmental triggers.
B. Radon is a radioactive gas that can cause lung cancer with long-term exposure, but it is not a common asthma trigger.
C. Mold is a common environmental allergen and asthma trigger. It can exacerbate asthma symptoms and lead to allergic reactions, so it is important for clients with asthma to avoid mold exposure.
D. Cockroaches are another common asthma trigger, and clients with asthma should avoid exposure to cockroach allergens.
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