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 ["A","B","C","E"]
Explanation
Choice A reason: The radiology department plays a crucial role in mass casualty incidents by providing imaging services to diagnose and assess the extent of injuries. Involving radiology in the drill planning process ensures that they are prepared to handle a sudden influx of patients.
Choice B reason: Hospital security is essential for managing crowd control, maintaining order, and ensuring the safety of patients, staff, and visitors during a mass casualty incident. Their involvement in the drill planning process is necessary to coordinate security measures effectively.
Choice C reason: Hospital housekeeping is responsible for maintaining cleanliness and sanitation, which is especially important during a mass casualty incident to prevent the spread of infections and ensure a safe environment for patient care. Their participation in the drill planning helps prepare them for increased demands.
Choice D reason: The dietary department, while important for overall patient care, is not immediately critical in the context of a mass casualty drill. The focus of such drills is typically on urgent medical care, security, and logistical coordination.
Choice E reason: The registration department is vital for efficiently processing and documenting patient information during a mass casualty incident. Their involvement in the drill planning process ensures that they are prepared to handle a large number of patients quickly and accurately.
Correct Answer is B
Explanation
Choice A reason: The red category in the START triage system is assigned to clients who require immediate life-saving intervention. Although this client is in pain and has severe symptoms, their respiratory rate, pulse, and capillary refill are normal, indicating that they do not need immediate life-saving intervention.
Choice B reason: The yellow category is designated for clients whose condition is stable but requires observation. This client is awake, alert, and oriented, with a normal respiratory rate, good radial pulse, and normal capillary refill. While they have severe abdominal pain and nausea, their condition does not appear to be life-threatening, making yellow the appropriate triage level.
Choice C reason: The black category is used for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is stable and responsive, so they do not fall into this category.
Choice D reason: The green category is for clients with minor injuries who can walk and do not require urgent medical attention. Since this client has severe symptoms and needs medical attention, the green category is not appropriate.
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