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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Scoliosis is characterized by an abnormal lateral curvature of the spine. This can result in an uneven shoulder height and an asymmetrical rib cage when viewed from the front or back. The spine may curve to the side, creating a noticeable "S" or "C" shape.
B. Lordosis, also known as hyperlordosis, is an excessive inward curvature of the lower back (lumbar spine). This condition makes the buttocks appear more prominent and the abdomen to protrude. The pelvis tilts forward, creating a pronounced curve in the lower back.
C. Pigeon chest, or pectus carinatum, is a condition where the chest protrudes outward, giving it a "pigeon-like" appearance. The sternum sticks out, creating a noticeable bulge in the center of the chest.

D. Kyphosis is characterized by an excessive outward curvature of the upper spine (thoracic spine), resulting in a hunchbacked or rounded appearance of the upper back. The back may appear rounded or hunched when viewed from the side.

A. Obtaining information about the client's respirations B. Auscultating lung sounds C. Assessing the strength of peripheral pulses D. Obtaining the client's temperature E. Performing a musculoskeletal and neurological examination F. Asking the client about a family history of any illness or disease

Correct Answer is ["A","B","D"]

Explanation

A. Assessing the client’s respirations is crucial in evaluating their respiratory status. This includes
checking the rate, rhythm, depth, and effort of breathing. Given the client’s symptoms of cough and lung congestion, it's important to assess whether there are any signs of respiratory distress or abnormal breathing patterns.
B. Auscultating lung sounds is essential to identify any abnormal lung sounds such as wheezes, crackles, or rhonchi. This helps in evaluating the presence and severity of lung congestion and can provide insights into the underlying cause of the client's symptoms.
C. While assessing peripheral pulses is important in a comprehensive cardiovascular assessment, it is not directly related to evaluating symptoms of a cold, cough, or lung congestion. The focus of the assessment for these specific symptoms would be more on the respiratory system.
D. Checking the client’s temperature is important because a fever may indicate an infection or inflammation, which can be associated with the symptoms of a cold or lung congestion. This helps in assessing the overall systemic response to the infection.
E. A musculoskeletal and neurological examination is not directly relevant to assessing symptoms related to a cold, cough, or lung congestion. These exams are more appropriate for evaluating physical function and neurological status, which are not the primary concerns in this scenario.
F. While family history can provide valuable context for some conditions, it is not the immediate focus for evaluating current symptoms like a cold, cough, or lung congestion. The priority should be on the present symptoms and their immediate effects on the client’s health.

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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?

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Naxlex Comprehensive Predictor Exams

Which abnormality is depicted in the image below?

Correct Answer is A

Explanation

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which assessments should the nurse include for this focused assessment? Select the three options that apply.

Correct Answer is ["A","B","D"]

Explanation

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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?

The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?