A client is exhibiting intercostal retractions and a tripod position. What priority assessment should the nurse consider next?
Auscultate the lung fields for audible wheezing or crackles.
Monitor blood pressure and heart rate.
Obtain a comprehensive social history.
Inspect the oral mucosa for color changes.
The Correct Answer is A
Choice A reason: Intercostal retractions and the tripod position are critical clinical indicators of respiratory distress and the use of accessory muscles to breathe. Auscultating for abnormal breath sounds is the priority assessment to determine the presence of airway obstruction, bronchospasm, or fluid accumulation, which guides emergency respiratory interventions.
Choice B reason: While monitoring vital signs is important, it is a secondary assessment in the setting of acute respiratory distress. The immediate priority is to identify the underlying cause of the respiratory failure through physical assessment of the airway and lung fields to guide life-saving oxygenation or ventilation interventions.
Choice C reason: A comprehensive social history is relevant to the broader clinical picture but is completely irrelevant during an acute respiratory crisis. In an emergency situation, the focus must remain entirely on the patient's airway, breathing, and circulation to prevent impending respiratory arrest or hypoxia-related injury.
Choice D reason: Inspecting the oral mucosa for cyanosis or color changes is a rapid assessment for hypoxia, but it does not provide the diagnostic data necessary to manage the respiratory distress. Auscultation provides essential information about the pulmonary etiology, which is required to determine the nature of the patient's life-threatening struggle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The bell of the stethoscope is a concave component designed specifically for detecting low-frequency sounds, such as the S3 or S4 heart sounds or low-pitched diastolic murmurs. When placed lightly against the skin, it allows low-frequency vibrations to pass through without being dampened, making it ineffective for high-pitched sounds.
Choice B reason: The tubing is a conduit for sound waves traveling from the chest piece to the earpieces. Its length, thickness, and internal diameter are optimized to minimize sound loss and ambient noise interference, but the tubing itself has no role in the filtering or specific auscultation of high-frequency versus low-frequency heart sounds.
Choice C reason: The earpieces are designed to ensure a comfortable and secure fit in the user's ear canals to exclude external ambient noise and direct sound into the ear. They do not possess any functional mechanism for frequency discrimination or the selective enhancement of high-pitched sounds during the cardiac examination process.
Choice D reason: The diaphragm is a stiff, flat disc that effectively transmits high-frequency sounds. It functions by filtering out low-frequency sounds while permitting high-pitched sounds, such as the S1 and S2 heart sounds and certain systolic murmurs, to pass through clearly, making it the essential component for standard cardiac assessment.
Correct Answer is A
Explanation
Choice A reason: A complete bowel obstruction is a surgical emergency because it carries a high risk of bowel ischemia, necrosis, and subsequent perforation. Preparing the client for an urgent surgical intervention, such as a laparotomy or resection, is the definitive and necessary treatment to restore bowel patency and prevent sepsis.
Choice B reason: A high-fiber diet is strictly contraindicated in a patient with a known complete bowel obstruction. Increasing bulk in the intestinal lumen will exacerbate the physical blockage, intensify peristaltic pressure against the obstruction, and significantly increase the risk of bowel perforation, thereby worsening the patient’s clinical condition.
Choice C reason: Increasing oral or systemic fluid intake in a patient with a complete bowel obstruction can lead to dangerous fluid sequestration within the bowel lumen proximal to the site of obstruction. This increases intraluminal pressure, risks vomiting and aspiration, and does not resolve the underlying physical blockage of the bowel.
Choice D reason: Administering an enema is absolutely contraindicated in cases of a complete bowel obstruction. The introduction of fluid and pressure into the colon distal to the obstruction site could cause catastrophic perforation of the bowel, leading to peritonitis and a systemic inflammatory response, significantly endangering the client's life.
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