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.

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Correct Answer is D

Explanation

A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.

A. Document information directly from a textbook. B. Copy previous nursing assessment. C. Document their findings. D. Seek clarification from a more experienced nurse.

Correct Answer is D

Explanation

A. Documenting information directly from a textbook is incorrect because textbooks provide general guidelines, not client-specific data. The student's assessment findings should be based on the actual client’s condition.
B. Copying a previous nursing assessment is incorrect and unethical. Each assessment must be conducted independently to ensure accurate and up-to-date client care.
C. Documenting findings without confidence in their accuracy can lead to errors in client care. If the student is uncertain, verification is necessary before documentation.
D. Seeking clarification from a more experienced nurse is correct. If a student nurse is unsure of their assessment findings, they should ask a preceptor or experienced nurse for guidance to ensure accuracy and safe client care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

Correct Answer is D

Explanation

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?

Correct Answer is D

Explanation

What is the primary purpose of a nursing health assessment?

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?

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?