The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

Pneumonia

Chronic emphysema

Pneumothorax

Congestive heart failure

Answer and Explanation

The Correct Answer is B

A. Pneumonia typically presents with fever, productive cough, and crackles rather than wheezing and tripod positioning.
B. Chronic emphysema is correct. The tripod position (leaning forward, hands on knees) is a classic sign of severe obstructive lung disease, such as emphysema or COPD. Wheezing and dyspnea at rest suggest air trapping and difficulty exhaling, which are hallmarks of this condition. The oxygen saturation of 91% is common in COPD patients due to chronic hypoxemia.
C. Pneumothorax presents with sudden onset chest pain, absent breath sounds on one side, and tracheal deviation (if severe) rather than wheezing.
D. Congestive heart failure can cause dyspnea but typically presents with crackles due to pulmonary edema rather than wheezing and tripod positioning.

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Correct Answer is A

Explanation

A. Having the client cough, then listening again is correct. Sometimes wheezing can be due to mucus or secretions in the airways, and coughing can help clear them. If wheezing persists, further assessment and interventions may be needed.
B. Teaching pursed-lip breathing is beneficial for chronic obstructive pulmonary disease (COPD) patients but is not the first action in an acute assessment.
C. Checking O₂ saturation and applying O₂ is important but not the first step. Oxygen therapy is not indicated unless there is evidence of hypoxia.
D. Administering a nebulizer treatment should only be done if wheezing persists and is causing respiratory distress, but the nurse should first confirm that the wheezing is not due to mucus plugging, which may resolve with coughing.

A. Review the client's blood work for sodium and bicarbonate levels. B. Assess the client for signs and symptoms of peptic ulcer disease. C. Assess the client's nutritional status. D. Assess the client for other signs and symptoms of liver disease.

Correct Answer is D

Explanation

A. Reviewing sodium and bicarbonate levels is not the most immediate action. While these lab values may provide useful information, they do not directly assess the suspected condition.
B. Assessing for peptic ulcer disease is incorrect because a tight, distended abdomen with visible arterioles (caput medusae) is more indicative of liver disease, such as cirrhosis or portal hypertension, rather than a gastric ulcer.
C. Assessing the client’s nutritional status may be important, but it is not the priority in this situation. Malnutrition can be a consequence of liver disease, but the nurse should first focus on identifying the underlying condition.
D. Assessing the client for other signs and symptoms of liver disease is correct. A distended abdomen and visible arterioles suggest possible ascites and portal hypertension, both of which are common in liver disease. Further assessment for jaundice, hepatic encephalopathy, or changes in liver enzyme levels would be appropriate.

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The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

Correct Answer is A

Explanation

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Correct Answer is D

Explanation

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