A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Abdominal retraction

Clubbing nails

Restlessness

Dependent edema 4+

Answer and Explanation

The Correct Answer is B

A.   Abdominal retraction is typically a sign of acute respiratory distress, not chronic respiratory insufficiency.
B.   Clubbing nails occurs as a chronic response to inadequate tissue oxygenation and is often associated with conditions like chronic obstructive pulmonary disease (COPD).
C.   Restlessness may occur during acute respiratory distress but is not a typical finding in chronic respiratory insufficiency.
D.   Dependent edema 4+ is more related to cardiac conditions such as heart failure rather than respiratory insufficiency, which generally results in more subtle signs like clubbing or cyanosis.

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Correct Answer is B

Explanation

A. This is a vibration felt on the chest wall when a patient speaks, often used to assess lung sounds. It is not associated with the crackling sensation described here.
B. The coarse, crackling sensation felt on the skin surface when palpating is crepitus, which occurs when air escapes into the subcutaneous tissue, often due to trauma, infection, or the presence of a pneumothorax.
C. These are abnormal lung sounds, such as crackles, wheezes, or rhonchi, heard with a stethoscope during auscultation, not felt on the chest wall during palpation.
D. A friction rub is a grating or scraping sound heard with a stethoscope, typically due to inflammation of the pleural surfaces. It is not a sensation felt on the chest wall.

A. Improper positioning B. Fatigue or weakness C. Respiratory distress D. Increased comfort and relaxation

Correct Answer is C

Explanation

A. Improper positioning does not apply in this case; the position described is often associated with respiratory distress.
B. Fatigue or weakness may be present, but the described position is more indicative of difficulty breathing.
C. Respiratory distress is suggested by the patient leaning forward, which is a common position for patients with shortness of breath as it helps expand the lungs and ease breathing.
D. Increased comfort and relaxation is unlikely; this position is more often associated with discomfort and difficulty breathing.

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A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

Correct Answer is B

Explanation

Mrs. Helms is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?

Correct Answer is C

Explanation

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