A nurse in the Emergency Department (ED) is caring for a client who is having acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?(Select all that apply)

Premature Ventricular Contractions (PVC's)

Respiratory Rate of 14 / min

Circumoral cyanosis

Retraction of sternal muscles

SpO2 95%

Answer and Explanation

Correct Answer : C,D

A.   Premature Ventricular Contractions (PVC's) (A) are related to cardiac activity and not directly indicative of respiratory function.
B.   A respiratory rate of 14 breaths per minute is within the normal range for adults (12-20 breaths per minute). Therefore, this finding does not indicate a decline in respiratory status.
C.   Circumoral cyanosis, which refers to a bluish discoloration around the mouth, indicates hypoxia and is a sign of deteriorating respiratory status. It suggests that the body is not getting enough oxygen, which is critical to monitor in an asthma attack.
D.   Retractions, especially of the sternal muscles, are a sign of increased work of breathing and can indicate severe respiratory distress. This finding suggests that the patient is struggling to breathe effectively, indicating a decline in respiratory status.
E.   An SpO2 of 95% is generally considered acceptable, especially in patients with asthma, as normal oxygen saturation levels typically range from 95% to 100%. While it is at the lower end of normal, it does not indicate an immediate decline in respiratory status.

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Correct Answer is A

Explanation

A. This type of shock occurs when there is widespread vasodilation leading to a relative hypovolemia, often seen in conditions like sepsis. Given that the patient has a surgical site infection, this is a plausible consideration. However, distributive shock typically involves more than just hypotension, including symptoms like warm skin and possible fever.
B. This type of shock results from significant fluid loss, leading to inadequate circulating volume. It can occur after surgery due to bleeding or fluid loss, but the context here suggests that the primary issue is infection rather than direct fluid loss.
C. Obstructive shock happens when there is a physical obstruction to blood flow, such as in cases of pulmonary embolism or tension pneumothorax. There’s no indication of obstruction in this scenario related to the infection and hypotension.
D. This shock type occurs when the heart fails to pump effectively, often due to myocardial infarction or severe heart failure. The patient’s history does not suggest heart dysfunction, so this option is less likely.

A. A bunion and bone deformity of the foot B. Ulnar deviation C. Nodules on the fingers D. Bone spurs on either knee

Correct Answer is A

Explanation

A. Hallux Valgus refers to a deformity where the big toe (hallux) angles towards the second toe, often accompanied by a bony bump (bunion) on the side of the foot. This condition can cause pain, discomfort, and difficulty in finding properly fitting footwear.
B. Ulnar deviation refers to the movement of the wrist where the hand deviates towards the ulnar bone (the side of the little finger). It is often associated with rheumatoid arthritis and not related to foot deformities.
C. Nodules on the fingers can occur in various conditions, including rheumatoid arthritis (called rheumatoid nodules). This term does not relate to Hallux Valgus or any deformity of the foot.
D. Bone spurs are bony projections that develop along the edges of bones, often related to osteoarthritis. While they can occur in the knees, they are not associated with Hallux Valgus.

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A nurse in the Emergency Department (ED) is caring for a client who is having acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?(Select all that apply)

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