A client reports “difficulty breathing and coughing up blood.” During the assessment, which of the following findings would require urgent intervention?
Steatorrhea during stool analysis.
Barrel chest identified on physical examination.
Oxygen saturation of 95% on 1 L oxygen via nasal cannula.
Hemoptysis of 300 mL reported by the client.
The Correct Answer is D
Choice A rationale: Steatorrhea during stool analysis, characterized by greasy, foul-smelling stools due to excess fat, is typically associated with malabsorption syndromes such as cystic fibrosis or chronic pancreatitis. While this warrants further evaluation, it is not directly linked to acute respiratory symptoms such as difficulty breathing or coughing up blood. Thus, this finding does not necessitate immediate intervention compared to the urgent risks posed by hemoptysis.
Choice B rationale: Barrel chest, often associated with chronic obstructive pulmonary disease (COPD), reflects long-term structural changes due to chronic air trapping. While it is an important finding requiring ongoing management, it is not an acute issue demanding urgent intervention. It does not directly explain symptoms like hemoptysis or respiratory distress, which indicate more critical underlying conditions requiring immediate attention.
Choice C rationale: An oxygen saturation of 95% on 1 L oxygen via nasal cannula is within the acceptable range for most individuals, with normal oxygen saturation values typically between 95% and 100%. This finding does not indicate severe hypoxemia or a deteriorating respiratory status. As such, it does not require urgent intervention compared to significant bleeding in the respiratory tract.
Choice D rationale: Hemoptysis of 300 mL is a critical finding requiring urgent intervention. This volume of blood indicates severe hemorrhage in the respiratory tract, which can compromise the airway, lead to hypovolemic shock, and cause respiratory failure if not addressed promptly. Immediate evaluation is necessary to identify the source of bleeding and initiate lifesaving treatments such as airway stabilization and hemorrhage control.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Rhinorrhea is a common manifestation of respiratory syncytial virus (RSV), as the virus causes inflammation of the upper respiratory mucosa leading to excessive nasal secretions. This inflammation and increased mucus production are the body's defensive response to eliminate the virus. The condition is most prevalent during early stages of infection and is often accompanied by other symptoms like cough and fever. The absence of other options makes rhinorrhea a characteristic feature in RSV.
Choice B rationale
Vesicles on the trunk are typically associated with varicella-zoster virus (chickenpox), not RSV. Vesicles form as the virus infects epithelial cells, leading to fluid-filled lesions that eventually crust over. This clinical presentation is entirely unrelated to the respiratory symptoms caused by RSV, which targets the respiratory epithelial cells rather than the skin.
Choice C rationale
Barrel chest develops as a chronic adaptation in diseases like emphysema and cystic fibrosis, where prolonged air trapping occurs. RSV predominantly affects younger children acutely, resulting in symptoms like rhinorrhea, cough, and wheezing without long-term anatomical alterations like barrel chest.
Choice D rationale
Clubbing of the fingers arises in chronic conditions like congenital heart disease or cystic fibrosis due to prolonged hypoxia and tissue growth factors affecting the nails. RSV is an acute respiratory virus, unlikely to lead to chronic hypoxia causing clubbing.
Correct Answer is B
Explanation
Choice A rationale
Bone marrow collection is not typically performed by positioning the child side-lying to expose the vertebrae. This position does not provide easy access to common collection sites such as the iliac crest. Instead, it is usually reserved for procedures involving the lumbar spine, such as lumbar punctures.
Choice B rationale
The prone position exposes the posterior iliac crest, which is the most common site for bone marrow aspiration and biopsy. This position provides optimal access while minimizing discomfort and maintaining stability in younger patients during the procedure.
Choice C rationale
The supine frog-like position is not suitable for bone marrow collection as it does not allow exposure to standard sites such as the iliac crest. This position may be more commonly used for pelvic procedures such as catheterization or genital examinations.
Choice D rationale
The sitting position with buttocks at the edge of the table is also inappropriate for bone marrow collection. This positioning fails to provide adequate exposure to the posterior iliac crest, a primary site for bone marrow aspiration. It may also compromise the child’s stability during the procedure.
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