A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?
The client has pneumonia in the bases.
The client has chronic respiratory disease.
The client has a funnel chest.
The client needs a cough suppressant.
The Correct Answer is C
A. The client has pneumonia in the bases: Crackles in the lung bases can suggest pneumonia; however, this finding alone does not confirm a diagnosis. Diagnosis requires clinical correlation with imaging findings such as consolidation or opacities and possibly labs. The physical deformity of the chest (sternal depression) is unrelated to the presence of pneumonia.
B. The client has chronic respiratory disease: While dyspnea and crackles may be seen in chronic respiratory diseases like COPD, the inspection finding of a depressed sternum is not characteristic of these conditions. An illness occurring for two days is also acute and cannot be termed chronic. Documenting a structural deformity based on inspection is more accurate than assuming a chronic disease.
C. The client has a funnel chest: Funnel chest, or pectus excavatum, is a deformity marked by a sunken appearance of the sternum, often more noticeable on inspiration. This is an accurate inspection-based finding that the nurse should document, separate from the respiratory symptoms.
D. The client needs a cough suppressant: A cough suppressant is a potential treatment option for symptomatic relief, but this does not relate to the inspection finding. The nurse’s role at this point is assessment and documentation, not treatment decisions based solely on visual inspection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Metabolic alkalosis: This condition results from excess bicarbonate or loss of acids through vomiting or diuretics. It is not associated with rapid, shallow breathing, especially in the early phase of heart failure.
B. Metabolic acidosis: Typically seen in states of increased acid production or bicarbonate loss, such as in renal failure or diarrhea. It is not the expected initial response to hyperventilation caused by early heart failure.
C. Respiratory alkalosis: Rapid, shallow breathing (tachypnea) leads to excessive exhalation of CO₂, resulting in decreased carbonic acid and increased blood pH. This is the typical early blood gas finding in acute heart failure due to hypoxia-driven hyperventilation.
D. Respiratory acidosis: This occurs when CO₂ is retained due to hypoventilation. Since the client is hyperventilating rather than hypoventilating, respiratory acidosis would not be present initially.
Correct Answer is A
Explanation
A. Alveoli: The alveoli are responsible for gas exchange, including the removal of CO₂. Impaired alveolar function leads to CO₂ retention and respiratory acidosis, commonly seen in conditions like COPD or pneumonia.
B. The pulmonary artery: The pulmonary artery carries deoxygenated blood to the lungs but does not directly participate in gas exchange. Impairment here affects perfusion, not CO₂ elimination.
C. The pulmonary vein: The pulmonary vein returns oxygenated blood to the heart and is not involved in gas exchange. Elevated CO₂ is not typically linked to vein function.
D. Bronchi: The bronchi conduct air but do not facilitate gas exchange. While obstruction can contribute to CO₂ retention, the alveoli are primarily responsible for its removal.
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