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 A

Explanation

Choice A reason: Furosemide, a loop diuretic, increases renal workload, risking kidney injury. Creatinine rises (>1.2 mg/dL) with reduced glomerular filtration, a critical marker to monitor for nephrotoxicity or dehydration in heart failure patients.

Choice B reason: Platelets (150,000-450,000/µL) assess clotting, unaffected by furosemide directly. Diuretics alter volume, not hematopoiesis, so monitoring platelets is irrelevant unless bleeding or unrelated conditions complicate the patient’s status.

Choice C reason: Chloride may drop with furosemide, but it’s less critical than creatinine. Hypochloremia affects acid-base balance, yet renal function takes priority, as kidney damage has broader, immediate implications in therapy.

Choice D reason: RBC count reflects anemia, not furosemide’s primary effects. Diuretics cause hemoconcentration if overused, but creatinine better captures renal impact, making red cell monitoring secondary in this context.

A. Auscultate Sara’s lung sounds. B. Measure Sara’s temperature. C. Encourage Sara to ambulate D. Document the treatment in her medical record.

Correct Answer is A

Explanation

Choice A reason: Auscultating lung sounds post-albuterol assesses treatment efficacy in asthma exacerbation. Reduced wheezing or improved air entry indicates bronchodilation, guiding further care, making it the priority to evaluate respiratory response immediately.

Choice B reason: Measuring temperature monitors infection, a possible asthma trigger, but it’s not the priority post-treatment. Albuterol targets acute bronchospasm, so assessing respiratory effect trumps systemic checks like fever in this moment.

Choice C reason: Encouraging ambulation is premature post-albuterol; patients need rest during exacerbation. It risks worsening dyspnea before confirming treatment success, making it less urgent than evaluating lung response to the bronchodilator.

Choice D reason: Documentation is essential but secondary to patient assessment post-treatment. Auscultating lung sounds first ensures albuterol’s effect is evaluated, as clinical response guides care before recording in the record.

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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 lab results should be monitored for a patient on furosemide?

Correct Answer is A

Explanation

Sara is receiving a nebulized albuterol treatment for her asthma exacerbation. Which of the following should be the nurse’s first priority after administering the treatment?

Correct Answer is A

Explanation

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