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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Potassium of 4.8 mEq/L is within normal range (3.5-5.0 mEq/L), posing no immediate threat. Hyperkalemia risks arrhythmias, but this level doesn’t warrant urgent action, as it’s stable and unlikely to disrupt cardiac function acutely.
Choice B reason: Dizziness and blurred vision suggest cerebral hypoperfusion or stroke, potentially from hypertension or embolism. These neurologic symptoms demand immediate action to assess and treat, as they indicate acute risk to brain function or life.
Choice C reason: Mild left ventricular hypertrophy on x-ray reflects chronic hypertension adaptation, not an acute emergency. It’s a stable finding requiring management, but it doesn’t necessitate immediate intervention compared to symptomatic neurologic changes.
Choice D reason: Blood pressure of 168/98 mmHg is elevated (stage 2 hypertension), risking long-term damage. Without acute symptoms, it’s less urgent than dizziness and vision changes, which signal immediate compromise needing rapid response.
Correct Answer is B
Explanation
Choice A reason: Pneumonia causes cough, chest pain, and dyspnea, not facial pain or nasal drainage primarily. Fever fits, but symptom location (lungs vs. sinuses) rules it out for these presenting complaints.
Choice B reason: Acute sinusitis matches pain over nose/eyes/forehead, purulent drainage, fever, and malaise. Bacterial or viral inflammation of sinuses causes these classic signs, aligning perfectly with the patient’s symptoms.
Choice C reason: Tuberculosis involves chronic cough, weight loss, and night sweats, not acute facial pain or drainage. It’s a lung infection, lacking sinus-specific symptoms, making it an unlikely diagnosis here.
Choice D reason: Pharyngitis causes throat pain, not sinus-area pain or nasal drainage. Fever and malaise fit, but the location and purulence point to sinusitis, not a pharyngeal infection, in this case.
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