Which of the following is an unexpected respiratory system assessment?
Bilateral lung sounds clear
No cough
Patient is using the incentive spirometer after surgery
Oxygen set at 2 liters via nasal cannula and oxygen saturation is 90%
The Correct Answer is D
Choice A reason: Clear bilateral lung sounds are a normal respiratory finding, indicating unobstructed airways and effective gas exchange. Abnormal sounds like wheezing or crackles would suggest pathology, but this choice reflects expected lung function, not an unexpected assessment outcome.
Choice B reason: Absence of cough is a normal finding, suggesting no airway irritation or obstruction. Coughing may indicate infection or fluid accumulation, but its absence aligns with healthy respiratory status, making this a typical and expected assessment result.
Choice C reason: Using an incentive spirometer post-surgery is an expected finding, as it promotes lung expansion and prevents atelectasis. It indicates patient compliance with respiratory therapy, a standard post-operative intervention, not an abnormal or unexpected respiratory assessment outcome.
Choice D reason: An oxygen saturation of 90% on 2 liters of oxygen via nasal cannula is unexpected, as normal saturation should be 95-100%. This suggests hypoxemia, potentially from lung pathology or inadequate oxygen delivery, warranting further investigation, making it the correct choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Difficulty initiating urination, incomplete bladder emptying, and dribbling in a 75-year-old male, with likely prostate enlargement on rectal exam, indicate benign prostatic hyperplasia (BPH). BPH obstructs the urethra, common in aging men. Accurate diagnosis guides treatments like alpha-blockers, preventing complications like urinary retention or kidney damage in elderly patients.
Choice B reason: Urinary tract infections cause burning or cloudy urine, not primarily dribbling or initiation issues, which suggest BPH in older males. Assuming UTI risks missing prostate issues, delaying BPH treatment. This could lead to untreated obstruction, increasing risks of retention or infection, requiring distinct diagnostic and therapeutic approaches.
Choice C reason: Stage 4 prostate cancer may cause urinary symptoms, but initiation difficulty and dribbling in older males typically indicate BPH, especially without systemic symptoms. Assuming cancer risks unnecessary invasive testing, delaying BPH management like medications, critical for relieving obstruction and improving quality of life in elderly patients.
Choice D reason: Renal disease causes systemic symptoms like edema or hypertension, not primarily urinary flow issues like dribbling, which point to BPH. Misdiagnosing as renal disease risks overlooking prostate obstruction, delaying treatments like tamsulosin, potentially worsening urinary retention or kidney strain in older males with BPH symptoms.
Correct Answer is C
Explanation
Choice A reason: Vital signs are objective, measurable data, not specific to musculoskeletal assessment or subjective experience. Pain, a subjective report, better fits the question. Assuming vital signs are subjective risks misclassifying data, leading to errors in prioritizing patient-reported symptoms like pain, critical for musculoskeletal care planning and intervention.
Choice B reason: Taking NSAIDs is a factual history, not a subjective assessment. Subjective data, like pain severity, reflect patient experience. Assuming medication use is subjective misaligns with assessment principles, risking neglect of patient-reported symptoms like pain, essential for evaluating musculoskeletal conditions and guiding effective pain management strategies.
Choice C reason: Pain rated 7 to 8 is subjective, based on the patient’s personal experience, central to musculoskeletal assessment for conditions like arthritis or injury. This guides pain management, like adjusting NSAIDs. Accurate identification ensures patient-centered care, addressing discomfort and improving function, critical for musculoskeletal health outcomes.
Choice D reason: Grimacing and holding a body part are objective, observable signs, not subjective reports. Pain severity, reported by the patient, is subjective. Assuming grimacing is subjective risks misclassification, potentially overlooking patient-reported pain levels, critical for tailoring interventions like analgesics in musculoskeletal assessment and care planning.
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