The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?

Clear and equal breath sounds bilaterally

Oxygen saturation of 98% on room air

Cough producing clear, thin sputum

Visible use of accessory muscles during inhalation

Answer and Explanation

The Correct Answer is D

A. Clear and equal breath sounds bilaterally

Explanation: Clear and equal breath sounds bilaterally indicate normal lung sounds, suggesting proper air exchange in both lungs. This is a normal finding and does not require immediate reporting.

B. Oxygen saturation of 98% on room air

Explanation: An oxygen saturation level of 98% on room air indicates adequate oxygenation of the blood. This is a normal and healthy oxygen saturation level and does not require immediate reporting.

C. Cough producing clear, thin sputum

Explanation: A cough producing clear, thin sputum is indicative of a non-infected or non-inflammatory condition in the respiratory system. Clear and thin sputum is often normal, especially in the absence of other symptoms. It does not require immediate reporting unless the client has other concerning symptoms.

D. Visible use of accessory muscles during inhalation

Explanation: Visible use of accessory muscles, such as neck or intercostal muscles, during inhalation suggests that the client is working hard to breathe. This could indicate respiratory distress, potentially due to conditions like asthma, COPD (Chronic Obstructive Pulmonary Disease), or other severe lung problems. It's a concerning sign and should be reported to the healthcare practitioner promptly for further evaluation and intervention.

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Correct Answer is D

Explanation

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

A. Indicates the beginning of diastole B. Coincides with the carotid artery pulse C. is louder than an S1 D. Is caused by the closure of the semilunar valves

Correct Answer is D

Explanation

A. Indicates the beginning of diastole: This statement is not accurate. S2, the second heart sound, indicates the end of systole and the beginning of diastole. It is specifically associated with the closure of the aortic and pulmonary valves.

B. Coincides with the carotid artery pulse: This statement is not accurate. S2 is associated with the closure of the aortic and pulmonary valves in the heart, not with the carotid artery pulse.

C. Is louder than an S1: This statement is not accurate. S1, the first heart sound, is usually louder than S2. S1 is associated with the closure of the mitral and tricuspid valves and marks the beginning of systole.

D. Is caused by the closure of the semilunar valves: This statement is accurate. S2 is caused by the closure of the aortic and pulmonary valves, which are the semilunar valves in the heart. It marks the end of systole and the beginning of diastole.

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The nurse is performing a respiratory assessment on a client. Which of the following findings should the nurse report to the practitioner?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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