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: Kyphosis, an exaggerated thoracic curvature, is expected in osteoporosis due to vertebral compression fractures from weakened bones, common in elderly patients. Recognizing this guides interventions like bracing or bisphosphonates, critical for preventing further fractures, improving posture, and reducing pain, enhancing quality of life in osteoporosis patients.
Choice B reason: Scoliosis, lateral spinal curvature, is typically congenital or idiopathic, not caused by osteoporosis, which leads to kyphosis. Assuming scoliosis risks misdiagnosis, diverting focus from fracture-related kyphosis, delaying treatments like calcium supplementation, critical for managing osteoporosis and preventing spinal deformities in elderly patients.
Choice C reason: Lordosis, exaggerated lumbar curvature, is not typical in osteoporosis, which primarily causes thoracic kyphosis from vertebral fractures. Misidentifying lordosis risks overlooking kyphosis, delaying interventions like physical therapy, essential for managing spinal deformities and preventing further bone loss in elderly patients with osteoporosis.
Choice D reason: Ankylosis, spinal joint fusion, is associated with ankylosing spondylitis, not osteoporosis, which causes kyphosis. Assuming ankylosis misguides assessment, risking neglect of osteoporosis-related fractures, delaying bisphosphonates or bracing, critical for preventing deformity progression and maintaining mobility in elderly patients with weakened bones.
Correct Answer is D
Explanation
Choice A reason: Cyanosis, indicating hypoxia, is not typical in alcohol use disorder with weight gain and abdominal tightness, which suggest liver issues like ascites causing jaundice. Assuming cyanosis risks misdiagnosis, delaying liver assessment or treatment, critical for managing complications like cirrhosis or portal hypertension in patients with chronic alcohol use.
Choice B reason: Erythema (redness) is unrelated to alcohol-related abdominal tightness and weight gain, which indicate liver dysfunction, often presenting with jaundice. Misdiagnosing erythema risks overlooking hepatic issues, delaying interventions like diuretics for ascites, essential for managing liver complications and improving outcomes in alcohol use disorder patients.
Choice C reason: Appearing normal is unlikely with alcohol use disorder causing weight gain and abdominal tightness, typically from ascites or liver damage, presenting as jaundice. Assuming normal risks missing serious liver pathology, delaying diagnosis and treatment, critical for preventing progression of cirrhosis or liver failure in affected patients.
Choice D reason: Jaundice, yellowing of skin, is likely in alcohol use disorder with abdominal tightness and weight gain, indicating liver dysfunction (e.g., cirrhosis or alcoholic hepatitis) causing ascites. Recognizing this guides urgent liver evaluation and treatments like abstinence or diuretics, critical for managing complications and improving survival in chronic alcohol users.
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