Patient Data
Click to highlight the assessment findings that require immediate follow up by the nurse.
Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.
mild subcostal retractions
Wheezes are noted throughout the lung fields
The client is pale
heart rate is 122 beats/minute
blood pressure 134/85 mm Hg
oxygen saturation 91% on room air
sitting in an upright position
The Correct Answer is ["A","B","C","D","F"]
Mild subcostal retractions: Subcostal retractions indicate that the muscles between the ribs are pulling inward during breathing. This is a sign of increased work of breathing and can indicate respiratory distress.
Wheezes noted throughout the lung fields: Wheezing is a high-pitched whistling sound produced during breathing, typically due to narrowed airways. It indicates airway obstruction, common in asthma exacerbations.
Client is pale: Pallor (pale skin) can indicate reduced oxygenation or perfusion to the tissues, which can occur during respiratory distress.
Heart rate of 122 beats/minute: Tachycardia (elevated heart rate) is a compensatory mechanism in response to decreased oxygen levels or increased respiratory effort.
Oxygen saturation 91% on room air: Oxygen saturation below 94% indicates hypoxemia (low blood oxygen levels), which is a critical finding requiring prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Rationale
The client is experiencing significant psychological distress characterized by intrusive thoughts and memories related to the traumatic event (house collapsing during a hurricane). These thoughts are causing her difficulty in falling asleep and impacting her emotional well-being. Her statement about feeling unable to get out of a "funk" suggests that she may be experiencing symptoms of acute stress or post-traumatic stress disorder (PTSD). It's crucial to address her psychological distress promptly to provide support and prevent exacerbation of her symptoms.
Sleep Difficulties: The client requests sleeping medication due to her difficulty in falling asleep. Sleep disturbances are common after experiencing a traumatic event and can further contribute to emotional distress and hinder recovery. It's important to assess her sleep patterns and consider appropriate interventions, such as pharmacological sleep aids under medical supervision, to help her achieve adequate restorative sleep.
Environment: The client expresses a preference for a quieter area of the unit away from constant noise (talking and alarms). Hospital environments can be noisy and disruptive, which can exacerbate anxiety and sleep difficulties. Ensuring she is in a quieter environment or making adjustments to minimize noise near her can improve her comfort and facilitate better sleep, which is essential for recovery and emotional well-being.
Correct Answer is B
Explanation
Rationale
A. Repositioning the stethoscope or reinflating the cuff may be necessary if the sounds are unclear or if there is difficulty in hearing the Korotkoff sounds, but these actions come after noting any auscultatory gap.
B. It's characterized by a period of silence between the appearance and disappearance of sounds. Noting its presence is important for accurately recording the blood pressure readings, as failure to recognize an auscultatory gap could lead to underestimating the systolic pressure.
C. After repositioning the stethoscope or noting the presence of an auscultatory gap, the nurse should proceed with the blood pressure assessment.
D. If the cuff was not inflated adequately during the initial inflation, the nurse may not have occluded the artery completely, leading to inaccurate readings. However, in this scenario where Korotkoff sounds
are heard, it indicates that the cuff pressure was sufficient to occlude and then release the artery's blood flow.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.