Upon assessment, the nurse noted a temperature of 102.1, respirations of 30 breaths per minute, oxygen saturation of 90% on room air, decreased expansion and dullness over the right lung, and crackles heard on the right lower lobe. Which condition should the nurse suspect?

Atelectasis

Pulmonary obstruction

Pneumonia

Bronchitis

Answer and Explanation

The Correct Answer is C

A.   Atelectasis refers to the collapse or incomplete expansion of a lung or a portion of a lung. It can cause decreased breath sounds and dullness upon percussion, but it is less likely to present with a fever as high as 102.1°F. However, atelectasis can occur secondary to an obstructive pneumonia, making the distinction important in clinical settings.
B.   Pulmonary obstruction, such as from an obstruction of the airway or bronchus, might cause symptoms like difficulty breathing and decreased oxygen saturation. However, it would less commonly present with fever and localized crackles.
C.   Pneumonia often presents with symptoms such as fever (elevated temperature of 102.1°F), increased respiratory rate (30 breaths per minute), decreased oxygen saturation (90% on room air), and abnormal lung findings. The decreased expansion and dullness over the right lung, along with crackles (rales) heard in the right lower lobe, are indicative of fluid accumulation and inflammation in the lung, which are characteristic of pneumonia.
D.   Acute bronchitis involves inflammation of the bronchi and is often associated with a cough, sputum production, and sometimes fever. However, it typically presents with a productive cough and wheezing rather than localized dullness and crackles confined to one lobe.

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Correct Answer is ["A","C","D"]

Explanation

A. An elevated temperature is often associated with infections and inflammation, including bronchitis. While a temperature of 99°F is slightly above normal and may indicate a mild fever, it is not a primary hallmark of bronchitis but rather a common response to infection or inflammation.
B. Fatigue is a general symptom that can accompany many conditions, including bronchitis. It is related to the overall feeling of being unwell and is not specific to bronchitis. While fatigue can be present, it is not a definitive sign of bronchitis on its own.
C. This includes findings such as bronchial breath sounds and rhonchi (a type of coarse, rattling sound) noted in the right lower lobe, which are indicative of bronchitis. The presence of rhonchi and bronchial breath sounds suggest inflammation and mucus in the airways, characteristic of bronchitis.
D. The use of accessory muscles for breathing is a sign of respiratory distress, which can occur in bronchitis when the airways are inflamed and obstructed. This finding is consistent with bronchitis as it reflects the increased effort required to breathe due to airway inflammation and mucus production.
E. The blood pressure reading of 110/54 mm Hg is within normal limits and does not provide specific information about bronchitis. Blood pressure is not typically a primary indicator for diagnosing bronchitis.
F. Bowel sounds are related to gastrointestinal function and do not provide information specific to bronchitis. Active bowel sounds are normal and do not help in diagnosing bronchitis.

A. The nurse should count the respirations in an unobtrusive manner without informing the client. B. The nurse should inform the client that they are preparing to count the client's respirations. C. The nurse should place a hand on the client's chest to count respirations. D. The nurse should count when the respirations are audible.

Correct Answer is A

Explanation

A. Counting respirations unobtrusively helps ensure the client does not alter their breathing pattern due to the awareness of being observed. This method is generally preferred because it provides a more accurate assessment of the client's normal respiratory rate.
B. If the client is informed that their respirations are being counted, they may unconsciously alter their breathing pattern due to nervousness or the desire to appear normal. This could result in an inaccurate assessment of their true respiratory rate.
C. Placing a hand on the client's chest can be helpful in assessing the depth and evenness of respirations. However, this method might cause the client to become aware of the assessment and could lead to a change in their breathing pattern.
D. Counting respirations only when they are audible can be problematic. Audible respirations are not always present and may not accurately reflect the client’s full respiratory rate. This method may miss periods of quiet breathing and thus provide an incomplete assessment of the respiratory rate.

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Upon assessment, the nurse noted a temperature of 102.1, respirations of 30 breaths per minute, oxygen saturation of 90% on room air, decreased expansion and dullness over the right lung, and crackles heard on the right lower lobe. Which condition should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department (ED) is admitting a client. Select 3 findings in the client's medical record that may be indicative of bronchitis.

Correct Answer is ["A","C","D"]

Explanation

The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?

Correct Answer is A

Explanation

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