A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.
Observe for signs and symptoms of respiratory distress.
Auscultate anterior and posterior lung fields.
Inspect the skin for pallor and cyanosis.
Assess the shape, expansion, and symmetry of the chest.
Observe rate, rhythm, and depth of respirations.
Correct Answer : A,B,C,E
A. Observe for signs and symptoms of respiratory distress.
B. Auscultate anterior and posterior lung fields.
C. Inspect the skin for pallor and cyanosis.
E. Observe rate, rhythm, and depth of respirations.
When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. A measurable client goal should be specific, observable, and
measurable. It should describe a behavior or outcome that the client can achieve. Identifying the five major drug side effects is specific and measurable. Sitting out of bed in a chair is too general, while verbalizing feelings about surgery at some point is not observable and not time-bound. Eating low sodium food is specific but not measurable.
Correct Answer is A
Explanation
The correct answer is choice A, carbohydrates, protein, and lipids. These three nutrients are referred to as macronutrients and are the main sources of energy for the body. Carbohydrates are the body's preferred source of energy, while protein and lipids can also be used for energy when carbohydrates are not available. The other three choices, vitamins, minerals, and water, are essential for various body functions, but they do not provide energy.
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