A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Assess respiratory rate and rhythm

Pulse oximetry reading

Assess bowel sounds

Auscultate lung sounds

Determine two touch discrimination in the lower extremities

Answer and Explanation

Correct Answer : A,B,D

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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Correct Answer is B

Explanation

A. Amber color. Normal urine color ranges from pale yellow to deep amber, depending on hydration. Amber urine alone is not abnormal.

B. White blood cells (WBC) 10. Normal WBC levels in urine should be ≤5 per high-power field (HPF). A count of 10 WBCs suggests infection or inflammation, such as a urinary tract infection (UTI).

C. pH 5.0. Normal urine pH ranges from 4.5 to 8.0, so a pH of 5.0 is within normal limits and does not require reporting.

D. Occasional casts. Occasional hyaline casts are normal, especially with dehydration or vigorous exercise. However, cellular casts (e.g., red blood cell casts) could indicate kidney disease.

A. Ask the client to push her legs and feet against the nurse's palms. B. Check the client's pedal pulses and feet for edema. C. Ask the client if she has been out of bed today. D. Ask the client how strong she feels today.

Correct Answer is A

Explanation

A. Ask the client to push her legs and feet against the nurse's palms. This action directly assesses the client’s muscle strength and ability to bear weight, which is essential before ambulation.

B. Check the client's pedal pulses and feet for edema. While circulatory assessment is important, it does not assess muscle strength, which is needed for safe ambulation.

C. Ask the client if she has been out of bed today. The client’s response does not objectively measure strength or readiness for ambulation.

D. Ask the client how strong she feels today. A client’s perception of strength may not be accurate and is not an objective way to assess readiness for ambulation.

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A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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