The medical-surgical charge nurse is conducting a training workshop for a group of new nurses. Which information would the nurse include in the training as secondary data sources of a client's respiratory system? Select all that apply.

Tuberculin skin test

Low socioeconomic status.

Complete blood count (CBC)

Male gender

Aral blood gases (ABG)

Chest x-ray

Answer and Explanation

Correct Answer : A,C,E,F

A. This is a diagnostic test used to determine if a client has been exposed to tuberculosis (TB). It is a secondary data source because it provides information about potential TB infection which can affect respiratory health.
B. While low socioeconomic status can impact health and access to healthcare, it is not a direct diagnostic tool or test for assessing the respiratory system. Instead, it is a social determinant that may influence health outcomes but does not provide direct data about the respiratory system itself.
C. A CBC is a laboratory test that provides information on various components of the blood, including red blood cells, white blood cells, and platelets. It can give insights into conditions that might affect the respiratory system, such as anemia or infections.
D. Male gender is a demographic characteristic rather than a diagnostic or data-gathering tool. While gender may influence the prevalence of certain respiratory conditions, it does not itself provide direct information or data about respiratory health.
E. ABG tests measure the levels of oxygen and carbon dioxide in the blood, as well as the blood’s pH balance. This test provides crucial information about a client’s respiratory function and is considered a secondary data source because it results from a specific diagnostic test rather than direct observation or physical assessment.
F. A chest x-ray is a diagnostic imaging test that provides detailed pictures of the lungs and chest cavity. It can reveal abnormalities such as infections, tumors, or fluid in the lungs. Since it is a test conducted outside of direct physical examination, it is classified as a secondary data source.

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Correct Answer is C

Explanation

A. Atelectasis refers to the collapse or incomplete expansion of a lung or a portion of a lung. It can cause decreased breath sounds and dullness upon percussion, but it is less likely to present with a fever as high as 102.1°F. However, atelectasis can occur secondary to an obstructive pneumonia, making the distinction important in clinical settings.
B. Pulmonary obstruction, such as from an obstruction of the airway or bronchus, might cause symptoms like difficulty breathing and decreased oxygen saturation. However, it would less commonly present with fever and localized crackles.
C. Pneumonia often presents with symptoms such as fever (elevated temperature of 102.1°F), increased respiratory rate (30 breaths per minute), decreased oxygen saturation (90% on room air), and abnormal lung findings. The decreased expansion and dullness over the right lung, along with crackles (rales) heard in the right lower lobe, are indicative of fluid accumulation and inflammation in the lung, which are characteristic of pneumonia.
D. Acute bronchitis involves inflammation of the bronchi and is often associated with a cough, sputum production, and sometimes fever. However, it typically presents with a productive cough and wheezing rather than localized dullness and crackles confined to one lobe.

A. The nurse should count the respirations in an unobtrusive manner without informing the client. B. The nurse should inform the client that they are preparing to count the client's respirations. C. The nurse should place a hand on the client's chest to count respirations. D. The nurse should count when the respirations are audible.

Correct Answer is A

Explanation

A. Counting respirations unobtrusively helps ensure the client does not alter their breathing pattern due to the awareness of being observed. This method is generally preferred because it provides a more accurate assessment of the client's normal respiratory rate.
B. If the client is informed that their respirations are being counted, they may unconsciously alter their breathing pattern due to nervousness or the desire to appear normal. This could result in an inaccurate assessment of their true respiratory rate.
C. Placing a hand on the client's chest can be helpful in assessing the depth and evenness of respirations. However, this method might cause the client to become aware of the assessment and could lead to a change in their breathing pattern.
D. Counting respirations only when they are audible can be problematic. Audible respirations are not always present and may not accurately reflect the client’s full respiratory rate. This method may miss periods of quiet breathing and thus provide an incomplete assessment of the respiratory rate.

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The medical-surgical charge nurse is conducting a training workshop for a group of new nurses. Which information would the nurse include in the training as secondary data sources of a client's respiratory system? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Upon assessment, the nurse noted a temperature of 102.1, respirations of 30 breaths per minute, oxygen saturation of 90% on room air, decreased expansion and dullness over the right lung, and crackles heard on the right lower lobe. Which condition should the nurse suspect?

Correct Answer is C

Explanation

The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?

Correct Answer is A

Explanation

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