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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C. Protein is most important for wound healing. After abdominal surgery, the client requires adequate protein to promote wound healing and tissue repair. Protein is essential for collagen synthesis, a protein that is responsible for the tensile strength of the wound. The recommended daily allowance for protein for an adult is 0.8 g/kg of body weight. Foods high in protein include meat, fish, poultry, dairy products, beans, and nuts.

A. Listen with a stethoscope at the second intercostal space left sternum B. Listen with the stethoscope at the fifth intercostal space at the sternum C. C. Listen with the stethoscope at the fifth intercostal space left mid clavicular line D. Listen with a stethoscope at the neck to the right of the coracoid process.

Correct Answer is C

Explanation

The correct answer is choice C: Listen with the stethoscope at the fifth intercostal space left mid clavicular line. This is the correct location to auscultate the apical pulse or apical heart rate. The apical pulse is the sound of the heart beating heard through a stethoscope placed over the apex of the heart, which is located at the fifth intercostal space at the left mid-clavicular line. The second intercostal space at the left sternum is the location to auscultate the aortic valve, while the fifth intercostal space at the sternum is the location to auscultate the tricuspid valve. The neck to the right of the coracoid process is not a location to auscultate the apical pulse.

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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.

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Explanation

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