When completing a focused respiratory assessment, which intervention should the practical nurse (PN) implement to assess for hemoptysis?
Observe the appearance of sputum.
Watch chest expansion on inspiration.
Determine how often the cough occurs.
Auscultate bilateral breath sounds.
The Correct Answer is A
A. Observe the appearance of sputum:
Hemoptysis is coughing up blood. The primary method of identifying it is by directly observing sputum color and content.
B. Watch chest expansion on inspiration:
Assesses ventilation and symmetry, but not presence of blood in sputum.
C. Determine how often the cough occurs:
Evaluates frequency but not the nature of sputum production.
D. Auscultate bilateral breath sounds:
Assesses air movement and adventitious sounds, but not the presence of blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
No explanation
Correct Answer is ["B","C","D"]
Explanation
A. Pulse rate 102:This is actually a normal heart rate for an infant (the typical range is 100 to 160 beats per minute). Pain usually causes tachycardia. If the infant were in significant pain, you would expect a heart rate much higher than 102.
B. Facial grimaces:In infants, facial grimacing, a furrowed brow, or chin quivering are among the most reliable behavioral indicators of pain.
C. Knees drawn to chest:Drawing the knees up to the chest is a classic behavioral sign of abdominal pain or distress in an infant, especially following abdominal surgery like a pylorotomy.
D. Restlessness:Restlessness, irritability, and the inability to be easily consoled are common signs that an infant's pain is not well-controlled.
E. Temperature 98.6° F (37.0° C):This is a normal body temperature. While a fever can sometimes be associated with the inflammatory response or infection, it is not used as a clinical indicator to assess the immediate effectiveness of an analgesic for acute postoperative pain.
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