The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

Respiratory rate of 20

Vesicular sounds heard in the lung periphery

Capillary refill time of 5 seconds

AP diameter of 1:2

Equal chest expansion

Answer and Explanation

The Correct Answer is C

A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.
B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.
C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.
D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.
E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.

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Correct Answer is C

Explanation

A. Supine is not recommended, as it can make breathing more difficult by limiting chest expansion.
B. Trendelenberg is not suitable for someone with breathing difficulties, as this position can worsen dyspnea.
C. High-Fowler is the best position for an asthma patient experiencing shortness of breath as it promotes lung expansion and allows for maximum chest wall movement.
D. Semi-Fowler may help but is less effective than High-Fowler in cases of acute respiratory distress.
E. Left-lateral does not optimize chest expansion and is not typically recommended for respiratory distress.

A. Normal sounds auscultated up against the sternum B. Bronchovesicular sounds that are normal over that location C. Bronchial sounds that are normal over that location D. Normal sounds auscultated over the trachea E. Vesicular breath sounds that are normal in that location

Correct Answer is E

Explanation

A. Normal sounds against the sternum would not be low-pitched or soft; they would typically be more pronounced.
B. Bronchovesicular sounds are medium-pitched and are not expected in the lower lobes; they are usually heard in the central area.
C. Bronchial sounds are high-pitched and hollow, typically heard over the trachea, not in the lower lobes.
D. Normal sounds over the trachea would not be described as low-pitched or soft.
E. Vesicular breath sounds are soft, low-pitched, and normal over peripheral lung fields, including the lower lobes, making this the correct interpretation.

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The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which position would the nurse place a 20 year old adult with asthma who is short of breath?

Correct Answer is C

Explanation

When auscultating the lungs of an adult client, the nurse notes that low-pitched, soft breath sounds are heard over the lower lobes. How would the nurse interpret these findings?

Correct Answer is E

Explanation

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