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 D
Explanation
Choice A reason: A blood pressure of 90/80 mmHg is below normal, indicating hypotension, especially with a low systolic value. Normal adult blood pressure, per guidelines, is around 120/80 mmHg. Low readings may suggest dehydration or cardiovascular issues, requiring evaluation, making this choice incorrect.
Choice B reason: A reading of 95/60 mmHg is hypotensive, with both systolic and diastolic values below normal ranges. Normal blood pressure is approximately 120/80 mmHg, per American Heart Association guidelines. Such low readings may indicate shock or autonomic dysfunction, rendering this choice incorrect.
Choice C reason: A blood pressure of 180/60 mmHg is abnormal, with elevated systolic pressure indicating hypertension and a low diastolic value suggesting possible aortic regurgitation. Normal blood pressure is 120/80 mmHg. This reading requires urgent assessment, making it an incorrect choice for normal adult values.
Choice D reason: A blood pressure of 120/80 mmHg is considered normal for adults, per current guidelines like those from the American Heart Association. It reflects balanced systolic and diastolic pressures, indicating healthy cardiovascular function without signs of hypertension or hypotension, making it the correct choice.
Correct Answer is C
Explanation
Choice A reason: Drainage, odor, appearance, and size provide incomplete wound documentation, missing critical details like location and depth. Comprehensive wound assessment requires precise measurements and site identification to track healing, guide treatment, and prevent complications like infection, making this choice insufficient for clinical standards.
Choice B reason: Size, odor, location, and depth omit key descriptors like appearance and drainage, which indicate infection or healing status. Wound documentation must include all measurable aspects to ensure accurate monitoring and treatment planning, rendering this choice inadequate for thorough medical records.
Choice C reason: Location, length, width, depth, appearance, and drainage form a complete wound description, capturing site, dimensions, tissue characteristics, and exudate. This comprehensive approach supports accurate tracking of healing, infection risk, and treatment efficacy, aligning with clinical guidelines for wound care documentation and management.
Choice D reason: Color, location, appearance, and drainage lack measurements like length, width, and depth, essential for monitoring wound progression. Omitting these quantifiable metrics hinders accurate assessment of healing or deterioration, making this choice incomplete for standardized wound documentation in clinical practice.
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