The patient complaints of dyspnea and the nurse is concerned the patient may need oxygen. What assessment will the nurse perform to determine if the patient needs supplemental oxygen?

Auscultate breath sounds.

Observe chest expansion

Measure capillary refill

Measure oxygen saturation

Answer and Explanation

The Correct Answer is D

A.   Auscultating breath sounds can provide valuable information about the presence of wheezing, crackles, or diminished breath sounds, which may indicate respiratory issues. However, while this assessment is important for understanding the underlying cause of dyspnea, it does not directly measure the patient's oxygenation status.
B.   Observing chest expansion can help the nurse assess the mechanics of breathing and whether there are any restrictions in lung expansion. While this assessment is useful, it does not provide a clear indication of the patient's oxygen saturation levels or immediate need for supplemental oxygen.
C.   Measuring capillary refill can give insights into peripheral perfusion and circulation, which can be affected by oxygenation. However, it is not the most direct or specific assessment for determining the need for supplemental oxygen in a patient with dyspnea.
D.   Measuring oxygen saturation (using a pulse oximeter) provides a direct and objective assessment of the patient's oxygenation status. Normal oxygen saturation levels typically range from 95% to 100%. If the oxygen saturation is below the acceptable range (usually less than 92% in many clinical settings), this would indicate the need for supplemental oxygen.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. A fracture involving the epiphyseal plate (growth plate) can lead to differential growth in the affected limb. If a fracture occurs before the growth plate has closed, it can potentially result in the shorter leg as the growth in that limb may be inhibited compared to the unaffected leg.
B. While scoliosis can lead to asymmetrical body positioning and potentially cause a perception of leg length discrepancy, it does not typically cause a true difference in bone length. Instead, scoliosis affects the spine's curvature and may alter posture, but it’s not a direct cause of one leg being shorter than the
other.
C. A comminuted clavicle fracture primarily affects the shoulder and does not impact leg length. It involves the upper limb and does not contribute to any differences in the lengths of the legs, making this option irrelevant to the observed leg length discrepancy.
D. JIA can lead to joint inflammation and may affect limb growth if it causes significant damage to the joints. However, while it can potentially cause some discrepancies in limb length due to joint issues, it is less directly associated with one leg being shorter than the other compared to an epiphyseal plate fracture.

A. A 33-year-old daycare worker at a high-risk center. B. A 54-year-old nurse working in a nursing home. C. A 16-year-old female high school student. D. A 43-year-old homeless man with a history of alcoholism.

Correct Answer is D

Explanation

A. While daycare workers can be at risk for various infections, they are not typically considered at high risk for TB unless they are in close contact with TB-positive individuals. Therefore, this option does not present the highest likelihood of TB.
B. This individual is at a moderate risk for TB, especially if they are caring for patients with known TB or are in an environment where TB may be more prevalent. However, nursing homes are more often associated with other infections rather than being primary sources for TB outbreaks.
C. High school students are generally not at high risk for TB unless they have specific exposure or travel history. Without additional risk factors, this group does not exhibit a high likelihood of TB.
D. This option represents the highest likelihood of TB. Homeless individuals are at increased risk for TB due to factors such as crowded living conditions, poor nutrition, and lack of access to healthcare.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The patient complaints of dyspnea and the nurse is concerned the patient may need oxygen. What assessment will the nurse perform to determine if the patient needs supplemental oxygen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a child during a well exam. The nurse discovers that one leg is shorter than the other. Which is most likely the cause of the difference in leg length?

Correct Answer is A

Explanation

The nurse is working in an outpatient clinic. The clinic has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today are most likely to have TB?

Correct Answer is D

Explanation

A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration?

Which of the following is a priority intervention to provide comfort for the child with pruritus associated with varicella zoster virus?

Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?

A patient has a respiratory rate of 36 breaths per minute. How would the nurse describe this respiratory pattern?

A nurse is admitting a client who has suspected retinal detachment. Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which identifiable cause of secondary hypertension?

The nurse is aware the early indicator of hypoxia in the unconscious client is: