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 B
Explanation
Choice A reason: Assessing pupils tests cranial nerves II (optic) and III (oculomotor), evaluating visual acuity and pupillary response, not cranial nerve I (olfactory), which governs smell. Pupil assessment is irrelevant to olfactory function, making this choice incorrect for testing the sense of smell.
Choice B reason: Cranial nerve I, the olfactory nerve, is responsible for the sense of smell. Instructing the client to identify a scent, such as coffee or vanilla, directly tests this nerve’s function. This is a standard neurological assessment method to evaluate olfactory integrity, making it the correct choice.
Choice C reason: Performing facial expressions tests cranial nerve VII (facial), which controls facial muscle movement. This is unrelated to cranial nerve I, which solely mediates olfaction. Facial expression assessment cannot evaluate smell, rendering this choice inappropriate for the specified cranial nerve test.
Choice D reason: Reading the Snellen chart tests cranial nerve II (optic) for visual acuity, not cranial nerve I, which is dedicated to smell perception. Visual testing does not assess olfactory function, making this choice incorrect for evaluating the olfactory nerve’s sensory capabilities.
Correct Answer is D
Explanation
Choice A reason: Providing a blueprint for patient-centered care describes the nursing process (assessment, diagnosis, planning, implementation, evaluation), guiding systematic care delivery. This is integral, unlike prescribing medications, a physician’s role. Assuming this is not part risks misunderstanding the process, critical for structured, effective nursing care in complex patient scenarios.
Choice B reason: Holistic care enhancing outcomes is central to the nursing process, addressing physical, emotional, and social needs through its steps. This contrasts with prescribing, which is medical. Assuming this is not part misaligns with the process’s purpose, risking fragmented care and reduced effectiveness in patient-centered nursing practice.
Choice C reason: A problem-solving approach for complex clients defines the nursing process, using data to address multifaceted needs systematically. Unlike prescribing, it’s a nursing responsibility. Assuming this is not part undermines the process’s role, risking ineffective care planning and interventions critical for managing complex patient conditions in clinical settings.
Choice D reason: Developing medication prescriptions is a physician’s role, not part of the nursing process, which focuses on assessment, diagnosis, planning, implementation, and evaluation. Nurses administer or educate about medications but don’t prescribe. This distinction ensures role clarity, preventing scope-of-practice errors and supporting collaborative, patient-centered care in healthcare settings.
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