A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

Diaphragmatic breathing

Controlled breathing

Pursed-lip breathing

Use of accessory muscles

Answer and Explanation

The Correct Answer is D

A. Diaphragmatic breathing:

Diaphragmatic breathing, also known as abdominal or deep breathing, is a normal and effective way of breathing. It involves the contraction and relaxation of the diaphragm, allowing for efficient lung expansion. This is a healthy and efficient breathing technique.

B. Controlled breathing:

Controlled breathing refers to a deliberate and regulated breathing pattern. It can include techniques such as paced breathing, where the individual consciously controls the rate and depth of their breaths. Controlled breathing is generally considered a positive and intentional approach to managing respiratory function.

C. Pursed-lip breathing:

Pursed-lip breathing is a breathing technique where the individual breathes in through the nose and exhales through pursed lips. This method is often taught to individuals with certain respiratory conditions, such as chronic obstructive pulmonary disease (COPD), to help improve lung function and alleviate shortness of breath. Pursed-lip breathing can be a helpful strategy in specific situations.

D. Use of accessory muscles:

The use of accessory muscles indicates that the person is experiencing increased difficulty in breathing. Accessory muscles, such as the neck and shoulder muscles, are not typically heavily involved in breathing under normal circumstances. When these muscles are visibly working during breathing, it suggests increased respiratory effort and can be a sign of respiratory distress or difficulty.

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Correct Answer is C

Explanation

A. Obtain a sputum sample:

This option is more relevant when the client is experiencing cough with sputum production, which might suggest respiratory issues. However, in the context of coughing after eating or drinking, the primary concern is likely related to the swallowing process rather than respiratory conditions.

B. Inspect the client’s tongue and mouth:

While inspecting the tongue and mouth is a good practice for assessing oral health, it may not directly address the issue of coughing after eating or drinking, which is more indicative of potential swallowing difficulties.

C. Perform a swallowing assessment:

This is the most appropriate option for the given scenario. A swallowing assessment helps identify any abnormalities or difficulties in the swallowing process, which could contribute to the client's coughing after eating or drinking.

D. Assess the client’s nutritional status:

While assessing nutritional status is important for overall health, it may not directly address the immediate concern of coughing after eating or drinking. Nutritional status assessment is a broader aspect of care.

Correct Answer is ["125"]

Explanation

To calculate the amount of mL that the client should receive, we need to use the formula:

mL = (g * 5 mL) / mg

where g is the ordered dose of the medication, mg is the concentration of the medication, and mL is the volume of the solution.

Plugging in the given values, we get:

mL = (4 g * 5 mL) / 160 mg

Simplifying, we get:

mL = 0.125 g/mL

Multiplying by 1000 to convert grams to milligrams, we get:

mL = 125 mg/mL

Therefore, the client should receive 125 mL of the solution.

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A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up on this assessment finding?

Correct Answer is C

Explanation

A client is ordered to receive 4 g of a medication. The pharmacy has the medication available in a concentration of 160 mg per 5 mL. How many mL should the client receive?

Correct Answer is ["125"]

Explanation

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