A nurse is performing a lung assessment on an older adult client and notes the following:

- Blood pressure: 136/90

- Pulse: 88 beats per minute

- Oxygen saturation: 92%

- Respiratory rate: 18 breaths per minute

- Lung sounds: Diminished breath sounds in all lung fields

What would the nurse expect to be happening with the client?

Client is experiencing a fluid deficit.

Adventitious sounds are present.

Hyperinflation of the lungs.

Client has a pectus carinatum.

Answer and Explanation

The Correct Answer is C

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Delaying follow-up for two weeks is inappropriate when symptoms suggest a possible serious metabolic disorder, such as diabetes. Immediate testing is needed.
B. Simply documenting the findings as benign is incorrect because hyperpigmentation in these areas (acanthosis nigricans) can be a sign of insulin resistance, which requires further evaluation.
C. Performing a random blood sugar test per order is correct. The symptoms of fatigue, thirst, and frequent urination, along with acanthosis nigricans, strongly suggest diabetes mellitus or insulin resistance. A random blood glucose test can help determine if the client has hyperglycemia.
D. While certain malignancies can be associated with acanthosis nigricans, diabetes is a more common cause. Asking about cancer history is not the priority intervention.

A. "The documentation satisfies legal standards established by health care organizations and institutions." B. "Documentation of the initial assessment becomes the foundation for the entire nursing process." C. "Incorrect conclusions may be made without the documentation of the nurse's opinions." D. "Health care institutions have established policies regarding documentation of initial assessments."

Correct Answer is B

Explanation

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

Correct Answer is C

Explanation

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Correct Answer is B

Explanation

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

What is the primary purpose of a nursing health assessment?

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?