Which physical assessment(s) would be pertinent to the patient with asthma? (Select All that Apply.)
Patient color
Lung sounds
Heart tones
Bowel sounds
Peripheral pulses
Respiratory rate and effort
Pulse oximetry reading
Peak expiratory flow
Correct Answer : A,B,C,F,G,H
A. The patient's color can indicate their oxygenation status. Cyanosis (bluish tint) may suggest hypoxia, which is critical to assess in an asthma patient.
B. Auscultation of lung sounds is essential in asthma assessment. The presence of wheezing, prolonged expiration, or decreased breath sounds can indicate airway obstruction and the severity of the asthma exacerbation.
C. Assessing heart tones can provide information about the cardiovascular response to respiratory distress. Increased heart rate may occur due to hypoxia or anxiety associated with asthma attacks.
D. Bowel sounds are not relevant in the assessment of asthma. While gastrointestinal symptoms may co- occur in some patients, they are not directly related to asthma's respiratory condition.
E. While peripheral pulses are important in general assessments, they do not provide specific information relevant to asthma management or respiratory status.
F. Monitoring respiratory rate and effort is crucial in assessing asthma. Increased respiratory rate and use of accessory muscles may indicate respiratory distress or an asthma exacerbation.
G. A pulse oximetry reading provides an objective measure of oxygen saturation. Low oxygen saturation levels indicate inadequate oxygenation, which is critical to monitor in asthma patients.
H. Measuring peak expiratory flow rate (PEFR) helps assess the severity of airway obstruction and monitor asthma control. It can guide treatment decisions and determine if an asthma attack is occurring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["400"]
Explanation
Total volume = 100 mL
Time = 15 minutes = 0.25 hours (15 minutes / 60 minutes/hour)
Infusion rate = Total volume / Time Infusion rate = 100 mL / 0.25 hours Infusion rate = 400 mL/hour
Therefore, the nurse should set the IV infusion pump to 400 mL/hour.
Correct Answer is B
Explanation
A. Hypertension, or high blood pressure, is a common condition in older adults but is not a specific indicator of pneumonia. While blood pressure can fluctuate with illness, it does not directly relate to the diagnosis of pneumonia.
B. Acute confusion is a critical and relevant sign in older adults with pneumonia. This demographic may experience altered mental status due to factors like hypoxia (low oxygen levels), fever, or dehydration. Confusion is often one of the first signs of infection in older patients, making it a significant assessment finding.
C. Hematemesis, which is the vomiting of blood, is not associated with pneumonia. It typically indicates a gastrointestinal issue, such as bleeding from ulcers or varices, rather than respiratory problems. Therefore, this finding would not be relevant to a pneumonia diagnosis.
D. While a cough is indeed a symptom of pneumonia, a dry hacking cough is less typical. Pneumonia generally presents with a productive cough (producing sputum) rather than a dry cough. A dry cough might suggest conditions like bronchitis or asthma.
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