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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is A
Explanation
A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.
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