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Patient Data

Exhibits

What finding(s) are cues for a respiratory problem? Select all that apply.

Sitting upright

Tightness in the chest

Medication compliance

Respirations of 28 breaths/minute

Restlessness

Dyspnea

Pulse oxygenation of 85%

Answer and Explanation

Correct Answer : A,B,D,E,F,G

A.   Patients with respiratory distress often prefer to sit upright or in a tripod position to ease breathing by allowing maximal lung expansion. Sitting upright helps relieve pressure on the diaphragm and allows better air exchange in the lungs.
B.   Chest tightness is a common symptom of various respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. It can result from bronchoconstriction, inflammation, or accumulation of mucus in the airways, leading to difficulty breathing.
D.   An increased respiratory rate (tachypnea) may indicate respiratory distress or difficulty breathing. Tachypnea is a compensatory mechanism to increase oxygen intake or remove carbon dioxide from the body when lung function is compromised.
E.   Restlessness can be a cue for a respiratory problem. Patients experiencing respiratory distress may exhibit restlessness due to hypoxia (low oxygen levels), discomfort, or anxiety related to difficulty breathing.
F.   Dyspnea, or shortness of breath, is a significant cue for a respiratory problem. It is a common symptom of various respiratory conditions, including asthma, COPD, pneumonia, and pulmonary embolism. Dyspnea may range from mild to severe and can significantly impact the patient's quality of life and functional status.
G.   A pulse oxygenation level of 85% indicates hypoxemia (low blood oxygen levels) and is a significant cue for a respiratory problem. Hypoxemia can result from various respiratory conditions or inadequate ventilation and may lead to tissue hypoxia and organ dysfunction if left untreated.
C. Medication compliance is not directly indicative of a respiratory problem. However, it may be relevant to managing respiratory conditions if the patient requires medications such as bronchodilators or corticosteroids to control symptoms or prevent exacerbations.
H. While an elevated heart rate (tachycardia) can be associated with respiratory distress, it is not specific to respiratory problems and may occur in response to other stressors or medical conditions.
I. Body mass index (BMI) is a measure of body fat based on height and weight and is not directly indicative of a respiratory problem. However, obesity is a risk factor for respiratory conditions such as obstructive sleep apnea and obesity hypoventilation syndrome.

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Correct Answer is B

Explanation

B. Comparing the client's pain scale rating with the prescribed dosing ensures that the nurse selects the appropriate medication and dosage based on the severity of the client's pain. This action helps ensure safe and effective pain management by matching the intensity of the client's pain with the appropriate analgesic medication and dose.
A. Although this may be relevant in some situations, particularly if the client's pain requires rapid relief, the nurse should prioritize selecting the medication and dose based on the severity of the client's pain rather than solely on the onset of action.
C. The process does not address the immediate need to select the appropriate analgesic medication for the client's pain.
D. This may not be appropriate, especially if the client is in pain or unable to make an informed decision about which medication to choose.

A. Fatigue. B. Lower extremity edema. C. Hepatomegaly. D. Jugular vein distension.

Correct Answer is A

Explanation

Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the systemic circulation. This leads to fatigue and exertional dyspnea.
B. Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.
C. Hepatomegaly is a typical finding in right ventricular dysfunction
D. Jugular vein dysfunction is a typical finding in right ventricular dysfunction.

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Patient Data

Exhibits

What finding(s) are cues for a respiratory problem? Select all that apply.