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: Fatigue is not part of BE FAST (Balance, Eyes, Face, Arms, Speech, Time) and is nonspecific, not a primary stroke sign. Facial drooping is critical. Assuming fatigue risks missing urgent stroke symptoms, delaying thrombolytic therapy, essential for minimizing brain damage within the critical time window.
Choice B reason: Fever is not in BE FAST and is not a primary stroke indicator, though it may occur later. Facial asymmetry is a key sign. Assuming fever misdirects assessment, risking delayed stroke recognition, critical for initiating rapid interventions like tPA to restore cerebral perfusion and reduce disability.
Choice C reason: Feet (balance) aligns with “B” in BE FAST, not “F,” which represents facial drooping. Misidentifying this risks confusing stroke assessment, potentially delaying recognition of facial asymmetry, a hallmark sign, critical for prompt stroke intervention to minimize neurological damage and improve patient outcomes.
Choice D reason: In BE FAST, “F” stands for face, assessing facial drooping or asymmetry, a common stroke sign due to cranial nerve VII involvement. It’s critical for rapid identification, enabling timely interventions like thrombolytics within 4.5 hours, minimizing brain damage and improving recovery chances in acute ischemic stroke patients.
Correct Answer is C
Explanation
Choice A reason: Normal blood pressure is <120/<80 mmHg, far below 148/92 mmHg, which is stage 2 hypertension per AHA guidelines. Assuming normal misclassifies the reading, risking untreated hypertension, leading to complications like stroke or heart failure. Accurate classification ensures proper management with lifestyle changes or medications.
Choice B reason: Stage 1 hypertension is 130-139/80-89 mmHg, lower than 148/92 mmHg, which is stage 2. Misclassifying as stage 1 underestimates severity, potentially delaying aggressive treatment like dual antihypertensives. Correct staging ensures timely intervention, critical for preventing cardiovascular damage in patients with elevated blood pressure readings.
Choice C reason: Stage 2 hypertension, per AHA, is ≥140/≥90 mmHg, matching 148/92 mmHg. This requires immediate lifestyle changes and likely medications to prevent cardiovascular events. Accurate classification guides treatment, ensuring blood pressure control, reducing risks of stroke, heart attack, or kidney damage in patients with significant hypertension.
Choice D reason: Elevated blood pressure is 120-129/<80 mmHg, below 148/92 mmHg, which is stage 2 hypertension. Assuming elevated underestimates the condition, risking inadequate intervention and progression to organ damage. Correct classification ensures appropriate management, critical for controlling hypertension and preventing long-term complications in affected patients.
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