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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.

Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.

Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.

Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.

A. Conduct a study about the time and money costs of implementing the change. B. Provide the staff with a questionnaire to quantify staff satisfaction with the changes. C. Compare the number of medication errors before and after the action was implemented. D. Establish a benchmark to identify a standard of performance.

Correct Answer is C

Explanation

Choice A reason: Conducting a study about the time and money costs of implementing the change is valuable for understanding the resource implications of the measures. However, it does not directly evaluate the effectiveness of the changes in reducing medication errors.

Choice B reason: Providing the staff with a questionnaire to quantify staff satisfaction with the changes can offer insights into how well the measures are being received by the staff and may indicate potential areas for improvement in implementation. Nonetheless, it does not measure the direct impact on medication error rates.

Choice C reason: Comparing the number of medication errors before and after the action was implemented is the most direct and effective method to evaluate the success of the changes. This approach allows the committee to measure the actual impact of the interventions on reducing medication errors, providing clear evidence of their effectiveness.

Choice D reason: Establishing a benchmark to identify a standard of performance is essential for setting goals and expectations. However, it is not a method for evaluating the success of changes that have already been implemented. It is more relevant for future goal-setting and performance measurement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Correct Answer is B

Explanation

As a member of the quality improvement committee, a nurse is evaluating the results of recently implemented measures designed to reduce medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

Correct Answer is C

Explanation

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