The nurse is assessing a client with a diagnosis of acute emphysema. The client is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which assessment findings should be reported to the provider immediately?
The client sits up and leans over the night table.
The client's respiratory rate is 8 breaths/min.
The client is noted to have a large barrel chest.
The client's lungs have fine bibasilar crackles on auscultation.
The Correct Answer is B
Choice A reason: This posture, known as the tripod position, is common among clients with emphysema as it helps them breathe more easily by using accessory muscles. While it indicates respiratory distress, it is not immediately life-threatening.
Choice B reason: A respiratory rate of 8 breaths/min is significantly below the normal range (12-20 breaths/min) and indicates hypoventilation, which can lead to life-threatening conditions such as hypercapnia (elevated carbon dioxide levels in the blood). This finding needs immediate attention from the provider.
Choice C reason: A barrel chest is a common physical finding in clients with chronic emphysema. It develops over time due to hyperinflation of the lungs but is not an urgent finding that needs immediate reporting.
Choice D reason: Fine bibasilar crackles can indicate fluid accumulation in the lungs or other lung pathology, but this finding alone does not necessarily require immediate intervention unless accompanied by other critical symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While touch can be used to convey interest and warmth, it is essential to recognize that its appropriateness varies among individuals, especially those with psychiatric disorders. The focus should be on understanding the client's comfort level with touch.
Choice B reason: Combining touch with empathy can be beneficial in some cases, but it may not always be appropriate for clients with psychiatric disorders. The individual's perception and comfort with touch should be taken into account before using it as a therapeutic tool.
Choice C reason: This statement acknowledges that touch can have different meanings for different individuals. It emphasizes the need for sensitivity and awareness of the client's personal boundaries and preferences, which is crucial in therapeutic communication with clients diagnosed with psychiatric disorders.
Choice D reason: Touch is not typically used as a primary method for deescalating volatile situations. Non-verbal cues and verbal communication techniques are often more effective and safer methods for managing such scenarios.
Correct Answer is C
Explanation
Choice A reason: Arranging for the client to remain on bedrest may not address the underlying reasons for the client's upset and agitation. While physical rest can be beneficial, it is more important to address the client's emotional and psychological needs through communication and support.
Choice B reason: Telling the client to remain calm can be perceived as dismissive and may not effectively alleviate their distress. It is important for the nurse to acknowledge the client's feelings and provide a supportive environment for them to express themselves.
Choice C reason: Encouraging the client to share their feelings is the best action to assist the client. By providing a supportive and empathetic environment, the nurse can help the client express their emotions, identify the cause of their distress, and work together to find appropriate solutions. This approach promotes therapeutic communication and can lead to a more accurate assessment and effective care plan.
Choice D reason: Giving the client time to rest and returning later for the assessment may delay addressing the client's immediate emotional needs. It is important for the nurse to engage with the client promptly to understand their concerns and provide support.
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