Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is C

Explanation

A. Hepatitis B is a viral infection and is not typically a concern for asthma patients in terms of environmental triggers.
B. Radon is a radioactive gas that can cause lung cancer with long-term exposure, but it is not a common asthma trigger.
C. Mold is a common environmental allergen and asthma trigger. It can exacerbate asthma symptoms and lead to allergic reactions, so it is important for clients with asthma to avoid mold exposure.
D. Cockroaches are another common asthma trigger, and clients with asthma should avoid exposure to cockroach allergens.

A. Encourage the patient to increase oral fluid intake. B. Apply humidification to the patient's oxygen. C. Suction the tracheostomy. D. Offer reassurance.

Correct Answer is C

Explanation

A. Encouraging the patient to increase oral fluid intake may help with secretion thinning over time, but in the immediate situation of thick respiratory secretions, it will not provide immediate relief.
B. Applying humidification to the oxygen would be helpful over time to thin secretions, but it is not the immediate action needed to address the difficulty in clearing thick secretions.
C. Suctioning the tracheostomy is the priority action in this situation. When a patient with a tracheostomy has difficulty clearing thick secretions, suctioning is the most effective way to relieve the obstruction and improve airflow, thereby addressing the immediate respiratory distress.
D. Offering reassurance is important, but it does not address the patient’s immediate need to clear the airway. Managing the respiratory distress should take priority.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

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