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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)

A.

Premature Ventricular Contractions (PVC's)

B.

Respiratory Rate of 14 / min

C.

Circumoral cyanosis

D.

Retraction of sternal muscles

E.

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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Related Questions

Correct Answer is B

Explanation

A. A positive ketone result indicates the presence of ketones in the urine, which can occur in conditions such as diabetes, fasting, or starvation. It is not indicative of a UTI.
B. A positive leukocyte esterase test indicates the presence of white blood cells (WBCs) in the urine, suggesting inflammation or infection, commonly associated with a UTI. This enzyme is released by WBCs, making it a key marker for infections.
C. The presence of crystals in the urine can indicate various conditions, including kidney stones or metabolic disorders, but it is not a specific marker for a UTI.
D. Hyaline casts may appear in the urine in response to dehydration or concentrated urine but are not specific to urinary tract infections. They can be seen in various renal conditions and do not indicate infection.

Correct Answer is D

Explanation

A. Neutropenia refers to an abnormally low level of neutrophils in the blood. This condition can result from various factors, including severe infections, bone marrow issues, or certain medications. However, in the context of a severe bacterial infection, you would expect an increase in neutrophils, not a decrease.
B. Anemia is a condition characterized by a lack of healthy red blood cells to carry adequate oxygen to the body’s tissues. While infections can lead to anemia, it is not a direct indicator of white blood cell production or response to a bacterial infection.
C. Leukopenia refers to a decrease in the overall white blood cell count. Like neutropenia, it indicates a reduced ability to fight infection, which is not consistent with a severe bacterial infection where the body is actively trying to produce more white blood cells.
D. A "left shift" indicates the presence of increased immature neutrophils (such as band cells) in the blood, which occurs when the bone marrow releases these cells into circulation in response to a severe infection. This reflects the body’s effort to combat an infection, typically seen in bacterial infections.

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