A patient presents with a respiratory rate of 28 breaths per minute. How would the nurse document this finding?
Bradypnea
Tachycardia
Tachypnea
Apnea
The Correct Answer is C
Rationale:
A. This term describes a slower-than-normal respiratory rate. In adults, bradypnea is usually defined as fewer than 12 breaths per minute. Bradypnea can be caused by factors such as drug overdose (especially opioids or sedatives), head injury affecting the respiratory center, hypothyroidism, or severe hypothermia. In this scenario, the patient’s respiratory rate is 28 breaths per minute, which is well above the normal adult range of 12–20 breaths per minute. Therefore, bradypnea is incorrect.
B. Tachycardia refers to an elevated heart rate, generally defined as a heart rate greater than 100 beats per minute in adults. It is important not to confuse heart rate terminology with respiratory rate terminology. Since this scenario only provides information about the patient’s breathing, not heart rate, tachycardia is not applicable.
C. Tachypnea is an abnormally rapid respiratory rate, typically defined as greater than 20 breaths per minute in adults. The patient’s rate of 28 breaths per minute falls clearly into this category. Tachypnea can result from a variety of conditions, including fever, anxiety, pain, hypoxia, pulmonary diseases (like asthma, pneumonia, or pulmonary embolism), metabolic acidosis (e.g., diabetic ketoacidosis), or heart failure. Accurately documenting tachypnea is essential, as it is an early indicator of respiratory distress or systemic illness and can guide further assessment and interventions, such as oxygen therapy, monitoring oxygen saturation, or evaluating for underlying causes.
D. Apnea is the complete absence of respirations. It may occur in conditions such as respiratory arrest, severe sleep apnea, or central nervous system depression. Since the patient is actively breathing at a rate of 28, apnea is clearly incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Inserting the otoscope deeply into the ear canal can cause discomfort, pain, or injury to the client’s ear. Proper technique requires gentle insertion just far enough to visualize the tympanic membrane without causing trauma.
B. Pulling the auricle downward and backward is appropriate for children under 3 years old, not adults. Using this technique on an adult may make visualization difficult and does not align with standard adult assessment guidelines.
C. Pulling the auricle upward and backward straightens the ear canal in adults, allowing proper visualization of the tympanic membrane. This technique reduces obstruction from the canal’s natural curve and facilitates accurate assessment while minimizing discomfort.
D. Asking the client to tilt the head forward is not necessary for otoscopic examination. The client should remain seated with the head in a neutral position while the nurse gently straightens the canal with the correct auricle maneuver. Tilting the head forward does not improve visualization.
Correct Answer is C
Explanation
Rationale:
A. Multiple open lesions on the lower legs are abnormal and may indicate infection, trauma, vascular compromise, or chronic conditions such as venous stasis ulcers. This finding requires further assessment and intervention, so it is not an expected skin finding.
B. Cyanosis around the lips indicates hypoxia or decreased oxygenation and is an abnormal finding. This requires immediate evaluation of the client’s respiratory and cardiovascular status. Cyanosis is never considered normal in adults.
C. Intact skin that is evenly pigmented is considered an expected and healthy finding in adults. It indicates that the skin is functioning properly as a protective barrier, has adequate perfusion, and shows no signs of injury, infection, or circulatory compromise.
D. Tented skin turgor indicates dehydration or loss of skin elasticity and is abnormal in adults. Normal skin turgor should return to its original position quickly when pinched. Persistent tenting reflects compromised fluid status or connective tissue changes.
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