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%
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 D
Explanation
A. While patients with latent TB may be treated to prevent progression to active TB, the treatment duration is generally shorter—typically around 3 to 9 months, depending on the medication regimen (e.g., isoniazid for 9 months or rifampin for 4 months).
B. Individuals with latent TB will usually test positive on a Mantoux test (also known as a tuberculin skin test), indicating they have been exposed to the TB bacteria. However, those with latent TB do not have active disease and may not have symptoms.
C. Individuals with latent TB do not spread the bacteria to others because the infection is contained and does not cause active disease. Only those with active TB can transmit the bacteria, regardless of sputum test results.
D. Patients with latent TB are not contagious and cannot spread the bacteria to others. The bacteria remain inactive in the body, and only a small percentage of these individuals may develop active TB in the future.
Correct Answer is A
Explanation
A. A sudden new pain in a patient with SCD can be a sign of a serious complication, such as acute chest syndrome or stroke. Prompt medical evaluation is crucial to identify and address any underlying complications.
B. While an X-ray may be helpful to rule out other causes of shoulder pain, it is not the most urgent priority in this case. The patient's sudden onset of pain could be a sign of a serious complication that requires immediate attention.
C. While a head-to-toe assessment is important for any patient, it is not the most urgent priority in this case. The patient's new pain could be a sign of a serious complication that requires immediate medical attention.
D. Increasing the opioid dosage may provide temporary relief from the pain, but it does not address the underlying cause of the new pain.
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