The experienced nurse understands that the student nurse may require additional instruction regarding proper respiratory assessment techniques when the nurse observes the student: (SELECT ALL THAT APPLY)

Listening to at least one full respiration in each location.

Instructing the client to breathe in and out rapidly while listening to breath sounds.

Listening to breath sounds through the hospital gown or clothing.

Instructing the client to take slow deep breaths through his or her nose.

Listening as the client inhales, then goes to the next site during exhalation.

Answer and Explanation

Correct Answer : B,C

Choice A reason: Listening to at least one full respiration in each location is a proper technique for respiratory assessment. It ensures that the nurse can accurately assess the breath sounds and identify any abnormalities. This method allows for a thorough evaluation of the respiratory system, ensuring that no areas are missed.

Choice B reason: Instructing the client to breathe in and out rapidly while listening to breath sounds is incorrect. Rapid breathing can lead to hyperventilation and may not provide an accurate representation of the client’s normal breath sounds. The proper technique is to instruct the client to take slow, deep breaths through their mouth, which allows for a more accurate assessment of the breath sounds and any potential abnormalities.

Choice C reason: Listening to breath sounds through the hospital gown or clothing is incorrect. Clothing can interfere with the sounds and may lead to inaccurate assessments. The proper technique is to place the stethoscope directly on the client’s skin to ensure that the breath sounds are heard clearly and accurately.

Choice D reason: Instructing the client to take slow deep breaths through his or her nose is partially correct but not ideal. While slow deep breaths are appropriate, they should be taken through the mouth to ensure that the breath sounds are more pronounced and easier to assess. Breathing through the nose can sometimes muffle the sounds and make it harder to detect abnormalities.

Choice E reason: Listening as the client inhales and then moving to the next site during exhalation is incorrect. The nurse should listen to both the inhalation and exhalation phases of respiration at each site. This ensures a complete assessment of the breath sounds and helps in identifying any abnormalities that may be present during either phase of respiration.

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Correct Answer is B

Explanation

Choice A reason:

Fever and bradypnea are not typical manifestations of asthma. Fever is more commonly associated with infections, and bradypnea (abnormally slow breathing) is not a characteristic symptom of asthma.

Choice B reason:

Dyspnea (shortness of breath) and wheezing are hallmark symptoms of asthma. Asthma is characterized by inflammation and narrowing of the airways, which leads to difficulty breathing and a whistling sound (wheezing) when exhaling. These symptoms are often triggered by allergens, exercise, or respiratory infections.

Choice C reason:

Crackles and a productive cough are more indicative of conditions like pneumonia or chronic bronchitis rather than asthma. Asthma typically involves a dry cough rather than a productive one.

Choice D reason:

A normal chest shape and orthopnea (difficulty breathing when lying flat) are not specific to asthma. While some individuals with severe asthma may develop a barrel chest over time due to chronic overinflation of the lungs, this is not a typical early manifestation.

A. Apply an iodine-soaked sterile dressing. B. Irrigate the wound and apply a dry sterile dressing. C. Apply a dressing and notify the surgeon. D. Apply a sterile dressing soaked with normal saline.

Correct Answer is D

Explanation

Choice A Reason:

Applying an iodine-soaked sterile dressing is not the best initial action. Iodine can be irritating to exposed tissues and may not provide the necessary moisture to protect the underlying tissue. The primary goal is to keep the tissue moist and prevent further damage.

Choice B Reason:

Irrigating the wound and applying a dry sterile dressing is not appropriate in this situation. Irrigation might cause further damage to the exposed tissue, and a dry dressing will not keep the tissue moist, which is crucial for preventing desiccation and promoting healing.

Choice C Reason:

Applying a dressing and notifying the surgeon is important, but the type of dressing is crucial. A dry dressing or an inappropriate dressing material can harm the exposed tissue. The nurse should first apply a moist dressing to protect the tissue and then notify the surgeon.

Choice D Reason:

Applying a sterile dressing soaked with normal saline is the most appropriate initial action. This type of dressing keeps the exposed tissue moist, which is essential for preventing further damage and promoting healing. Normal saline is gentle and will not irritate the tissue, making it the best choice for initial wound care.

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The experienced nurse understands that the student nurse may require additional instruction regarding proper respiratory assessment techniques when the nurse observes the student: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is completing an admission assessment on a client diagnosed with asthma. What clinical manifestations are typical of the disorder?

Correct Answer is B

Explanation

The nurse is changing a client’s abdominal dressing and notes a separation of the incision line. The underlying tissue is protruding from the wound. The nurse should plan to do which of the following in the initial care of this wound?

Correct Answer is D

Explanation

Which of the following postoperative patients is at greatest risk for respiratory complications?

The nurse is preparing to teach a client how to effectively perform pursed-lip breathing. The nurse would include which intervention in the teaching?

The nurse is caring for a client recently diagnosed with emphysema. What information, regarding health maintenance, would the nurse include in teaching sessions? (SELECT ALL THAT APPLY)

Which is the best method for the nurse to correctly identify a client prior to surgery?

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The nurse recognizes the assessment data which best indicates that the client diagnosed with asthma is achieving good control with the prescribed medication regimen is when:

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