Based on the physical exam findings, which assessment indicates the client’s condition is worsening?

Cyanotic mucous membranes and oxygen saturation of 84% on 3 L nasal cannula.

Diffuse wheezing auscultated throughout lung fields and hand tremor present.

Blood pressure of 168/90 mm Hg and heart rate of 98/min.

Clear rhinorrhea visible and skin warm and dry.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Cyanotic mucous membranes and oxygen saturation of 84% indicate severe hypoxemia. Normal oxygen saturation is 95–100%. The cyanosis suggests inadequate tissue oxygenation, requiring immediate intervention to prevent respiratory failure.

Choice B rationale

Diffuse wheezing and tremors may signify severe airway obstruction or beta-agonist overuse. While concerning, these findings are not as immediately life-threatening as hypoxemia and cyanosis.

Choice C rationale

Elevated blood pressure (168/90 mm Hg) and heart rate (98/min) may indicate stress or pain but do not reflect acute life-threatening changes compared to severe hypoxemia.

Choice D rationale

Clear rhinorrhea and warm, dry skin may suggest mild upper respiratory infection. These findings do not indicate imminent danger or severe respiratory compromise compared to hypoxemia and cyanosis.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Orange slices pose a choking risk due to their firm texture and fibrous membranes, making them inappropriate for a mechanical soft diet.

Choice B rationale

Ground hamburger has a soft consistency and is easily chewable, meeting the requirements of a mechanical soft diet.

Choice C rationale

Cooked green beans are soft and easy to chew, aligning with the dietary restrictions of a mechanical soft diet.

Choice D rationale

Canned peaches are soft and can be mashed easily, making them suitable for a mechanical soft diet.

A. Administer supplemental oxygen. B. Prepare for chest tube insertion. C. Administer IV fluids. D. Obtain a repeat chest x-ray.

Correct Answer is B

Explanation

Choice A rationale: Administering supplemental oxygen may temporarily improve oxygenation but does not address the underlying cause of pneumothorax. The primary intervention should focus on relieving the air pressure in the pleural space.

Choice B rationale: Inserting a chest tube is the definitive treatment for pneumothorax. It allows air to escape from the pleural space, re-expanding the lung and relieving symptoms such as chest pain and shortness of breath.

Choice C rationale: Administering IV fluids may support blood pressure but does not directly address pneumothorax. The client needs immediate intervention to relieve the air trapped in the pleural space.

Choice D rationale: Obtaining a repeat chest x-ray can confirm the diagnosis but does not provide immediate relief for pneumothorax. The primary focus should be on initiating treatment to resolve the condition promptly.

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Based on the physical exam findings, which assessment indicates the client’s condition is worsening?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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