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 D
Explanation
Rationale:
A. A 2 cm erythematous lesion is objective data because it can be observed, measured, and verified by the nurse. Objective data are factual and measurable rather than based on the patient’s personal experience.
B. Skin that is warm and dry to touch is also objective data. The nurse can palpate and assess these characteristics directly, making them measurable and independent of the patient’s perception.
C. Capillary refill of 2 seconds is an objective finding, as it is measurable and can be verified through observation. This data provides information about peripheral perfusion rather than the patient’s personal experience.
D. The client reporting itching on both arms is subjective data, because it reflects the patient’s personal perception and experience. Subjective data cannot be directly measured or observed, but it is essential for understanding symptoms, guiding care, and identifying potential skin conditions such as dryness, allergy, or dermatitis.
Correct Answer is B
Explanation
Rationale:
A. Capillary refill time does not directly measure oxygenation of arterial blood. Oxygenation is better assessed using tools such as pulse oximetry (SpO₂) or arterial blood gases (ABGs). A delayed refill does not specifically indicate oxygen levels but rather reflects how well blood is reaching peripheral tissues.
B. Normal capillary refill is typically less than or equal to 2 seconds in adults. A refill time of 5 seconds is significantly delayed, indicating that blood is not returning promptly to the capillaries. This suggests decreased peripheral perfusion, which may occur in conditions such as shock, hypovolemia, dehydration, peripheral vascular disease, or decreased cardiac output. This is a clinically important abnormal finding that requires further assessment.
C. Increased capillary blood flow would result in a faster (not slower) refill time, typically under 2 seconds. A 5-second refill clearly indicates the opposite—reduced blood flow to the extremities.
D. A refill time of 5 seconds is not normal. Normal capillary refill indicates adequate circulation and should occur within 2 seconds. A delayed refill is a warning sign of impaired circulation and should not be interpreted as normal.
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