Based on the patient’s respiratory assessment and history, which assessment finding would indicate a worsening of Maria’s respiratory status?

Respiratory rate decreases to 18 breaths per minute.

Oxygen saturation increases to 90% on 2 L oxygen via nasal cannula.

Increased use of accessory muscles for breathing.

Productive cough with yellowish sputum.

Answer and Explanation

The Correct Answer is C

Choice A reason: Respiratory rate dropping to 18 breaths/min may suggest improvement or fatigue, not worsening, in respiratory status. Normal range (12-20) makes this less alarming than signs of increased breathing effort.

Choice B reason: Oxygen saturation rising to 90% on 2 L indicates better oxygenation, not worsening. It reflects treatment response, improving gas exchange, so this finding contradicts a decline in respiratory status.

Choice C reason: Increased accessory muscle use signals worsening respiratory distress, as it compensates for airway resistance or fatigue. It reflects higher work of breathing, a critical sign of decompensation needing intervention.

Choice D reason: Productive cough with yellowish sputum suggests infection, not immediate worsening of respiratory mechanics. It’s a chronic sign, less urgent than accessory muscle use indicating acute respiratory effort escalation.

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Correct Answer is D

Explanation

Choice A reason: Restricting fluids to 2 liters per day increases blood viscosity in sickle cell disease, promoting sickling and vaso-occlusion. Adequate hydration is critical to dilute hemoglobin S, so this instruction contradicts evidence-based management for crisis prevention.

Choice B reason: Iron supplements are contraindicated in sickle cell disease unless anemia is iron-deficient, which is rare. Most patients have normal or high iron from hemolysis, so a multivitamin with iron risks overload and organ damage.

Choice C reason: Avoiding caffeine lacks evidence in sickle cell crisis prevention; it’s not a trigger. Moderate intake doesn’t dehydrate significantly or affect sickling, making this instruction irrelevant to discharge teaching for this condition.

Choice D reason: Limiting crowd exposure reduces infection risk, a common sickle cell crisis trigger. Infections cause inflammation and hypoxia, promoting sickling, so this instruction aligns with preventing complications and maintaining patient stability post-discharge.

A. Collaborate With Speech Therapist to assess swallowing ability B. Collaborate With Physical Therapist to develop a plan for active range of motion and early mobility. C. Collaborate With the Respiratory Therapist to provide tracheostomy care D. Collaborate With the Dietitian to recommend a diet to promote nutrition

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

Explanation

Choice A reason: Speech therapists assess swallowing in tracheostomy patients, as the tube alters airway dynamics. Collaboration ensures safe oral intake, preventing aspiration, a critical task aligning with their expertise in dysphagia management.

Choice B reason: Physical therapists plan mobility in tracheostomy care, enhancing strength and preventing atrophy. Collaboration promotes early activity, improving respiratory muscle function and recovery, tailored to the patient’s physical capacity.

Choice C reason: Respiratory therapists provide tracheostomy care, like suctioning and cuff management, maintaining airway patency. Collaboration ensures proper technique, reducing infection or obstruction risks, a core responsibility in respiratory support.

Choice D reason: Dietitians recommend nutrition plans for tracheostomy patients, addressing caloric and swallowing needs. Collaboration optimizes healing and energy, adjusting diets (e.g., thickened liquids) to support recovery and prevent complications.

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Based on the patient’s respiratory assessment and history, which assessment finding would indicate a worsening of Maria’s respiratory status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction will the nurse plan to include in discharge teaching for a patient who was admitted with a sickle cell crisis?

Correct Answer is D

Explanation

Nursing management of patients with tracheostomies includes collaboration with other healthcare team members. Match the Health care team member with the correct collaborative task.

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

Explanation

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