A nurse is evaluating and assessing a client with a diagnosis of chronic emphysema. The client is receiving oxygen therapy at a flow rate of 5 L/min via nasal cannula. Which findings concern the nurse immediately?

The client sitting up and leaning over the bedside table,

Fine bilateral basilar crackles.

A respiratory rate of 9 breaths/min.

A large barrel chest.

Answer and Explanation

The Correct Answer is C

A.   This position is often seen in clients with chronic respiratory conditions like emphysema. It is called the tripod position and can help the client breathe more easily by expanding the chest and reducing the work of breathing. While this position indicates the client is experiencing difficulty breathing, it is not an immediate emergency but rather a sign of their chronic respiratory condition.

B.   Fine crackles (or rales) are abnormal lung sounds that can indicate fluid in the alveoli. In emphysema, crackles are not typical and may suggest a complication such as pulmonary edema or infection.
However, if these crackles are not severe and the client’s overall condition is stable, it may not be the
most urgent issue compared to other findings.
C.   A respiratory rate of 9 breaths per minute is considered bradypnea, which is significantly lower than the normal range (12-20 breaths/min). For a client with chronic emphysema on oxygen therapy, bradypnea is a concerning finding because it indicates inadequate respiratory drive and potential respiratory depression.
D.   A barrel chest is a common physical finding in clients with chronic emphysema due to chronic air trapping and lung overexpansion. It reflects long-standing changes in the chest structure due to the disease. While it is a notable finding, it is a chronic manifestation of emphysema and not an immediate concern in the context of acute clinical status.

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Correct Answer is D

Explanation

A. While abnormal bronchial breath sounds can indicate underlying pathology, they are not typically considered immediately life-threatening.
B. Wheezing is a common symptom of asthma and other conditions that cause airway narrowing. While it can be uncomfortable and distressing, it is not typically considered a life-threatening emergency.
C. Absent breath sounds can indicate a collapsed lung or other serious respiratory condition. However, it is not as immediately life-threatening as stridor, which indicates a severe airway obstruction.
D. Stridor is a high-pitched, wheezing sound caused by obstruction or narrowing of the upper airway (larynx or trachea). It is often associated with conditions like croup, epiglottitis, or an allergic reaction leading to airway swelling. Stridor indicates a significant obstruction in the upper airway that can rapidly lead to severe respiratory distress or compromise.

A. Request a mammogram. B. Review the clients medication list for drugs that have gynecomastia as a side effect. C. Request a breast biopsy. D. Proceed with the examination, this is a normal part of the aging process.

Correct Answer is B

Explanation

A. While mammograms are commonly used to evaluate breast tissue in women, they are not typically used for men. In men, gynecomastia is usually evaluated with a physical exam and sometimes ultrasound rather than mammography. A mammogram might be ordered if there is a suspicion of breast cancer, but this is less common and not the first step in evaluating gynecomastia.
B. This is a prudent and effective next step. Certain medications can cause gynecomastia as a side effect, including some antipsychotics, antidepressants, antiandrogens, and calcium channel blockers. Reviewing the medication list can help identify if the gynecomastia might be related to a drug the client is taking.
C. A breast biopsy is an invasive procedure used to diagnose breast cancer or other conditions when there is a concern about a mass or abnormality. If gynecomastia is the only finding and there are no concerning features such as a palpable mass or other symptoms, a breast biopsy would not be the first step.
D. While gynecomastia can occur as a normal part of aging, especially in older men due to hormonal changes, it is important to evaluate it thoroughly to rule out other causes. Simply dismissing it as a normal part of aging without further investigation might overlook an underlying condition or medication side effect.

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A nurse is evaluating and assessing a client with a diagnosis of chronic emphysema. The client is receiving oxygen therapy at a flow rate of 5 L/min via nasal cannula. Which findings concern the nurse immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding is most likely to be immediately life-threatening?

Correct Answer is D

Explanation

During an examination of a 57-year old man, you note gynecomastia. Your next best action is what?

Correct Answer is B

Explanation

The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse document?

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