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: Smoking history is relevant for vascular or lung issues but not directly for unilateral arm edema, which suggests localized causes like lymphedema. Breast surgery history is more pertinent. Assuming smoking is key risks missing lymphatic causes, delaying diagnosis and management of edema in affected patients.
Choice B reason: Left arm edema may indicate lymphedema from breast surgery, like mastectomy, which disrupts lymphatic drainage. Asking about surgery history is critical to identify causes, guiding interventions like compression therapy. This targeted question ensures accurate diagnosis, preventing complications like chronic swelling or infection in patients with post-surgical edema.
Choice C reason: Recent weight gain may cause generalized edema but is less likely for unilateral arm edema, which points to localized issues like post-surgical lymphedema. Assuming weight gain is key risks overlooking specific causes, delaying targeted treatments critical for managing localized edema and improving patient comfort and function.
Choice D reason: Extra nipples (supernumerary nipples) are anatomical variants, unrelated to arm edema, which likely stems from lymphatic or vascular issues. Assuming this is relevant misdirects assessment, risking neglect of surgical history, critical for diagnosing lymphedema and implementing appropriate interventions like lymphatic drainage or compression.
Correct Answer is A
Explanation
Choice A reason: The descending colon is located in the left lower quadrant (LLQ), descending along the left abdomen. Assessing this area detects abnormalities like diverticulitis or masses. Accurate localization ensures targeted examination, guiding diagnosis and interventions, critical for managing colorectal conditions and preventing complications in abdominal assessments.
Choice B reason: The right lower quadrant (RLQ) contains the appendix and cecum, not the descending colon, which is in the LLQ. Misidentifying this risks incorrect assessment, potentially missing LLQ issues like colitis, delaying diagnosis and treatment, critical for addressing colorectal pathology in patients with abdominal symptoms.
Choice C reason: The right upper quadrant (RUQ) includes the liver and gallbladder, not the descending colon, located in the LLQ. Assuming RUQ misguides assessment, risking oversight of LLQ conditions like diverticulitis, delaying targeted interventions, essential for accurate diagnosis and management of abdominal issues in clinical practice.
Choice D reason: The left upper quadrant (LUQ) contains the stomach and spleen, not the descending colon, which resides in the LLQ. Misidentifying this risks missing LLQ pathology like masses or inflammation, delaying diagnosis and treatment, critical for effective abdominal assessment and management of colorectal conditions in patients.
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