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 A
Explanation
Choice A reason: Using an interpreter enhances client satisfaction by ensuring clear communication, respecting language needs, and fostering trust. This improves patient engagement and care quality, critical for positive healthcare experiences. Accurate language support prevents misunderstandings, ensuring clients feel heard and valued, especially in diverse populations with language barriers.
Choice B reason: Interpreters increase initial costs due to service fees, not decrease them. The focus is on communication accuracy and satisfaction, not cost reduction. Assuming cost savings misaligns with interpreter use, risking neglect of language needs, which could lead to errors or dissatisfaction in patients with limited English proficiency.
Choice C reason: Interpreters increase communication accuracy by bridging language gaps, ensuring precise health history collection and reducing errors in diagnosis or treatment. This is critical for safe, effective care in non-English-speaking patients, preventing misinterpretations that could compromise health outcomes and patient safety in clinical settings.
Choice D reason: While interpreters may indirectly support self-esteem by respecting language needs, this is not a primary reason for their use. Accuracy and satisfaction are key. Assuming self-esteem is the focus risks prioritizing emotional over practical needs, potentially neglecting communication accuracy critical for effective health history and care planning.
Correct Answer is A
Explanation
Choice A reason: Stage 4 pressure injury involves full-thickness tissue loss with exposed muscle, bone, or tendon, as described with a deep depression and visible bone. This severe stage requires aggressive interventions like debridement or surgery. Accurate staging ensures proper wound care, preventing infection and promoting healing in advanced pressure injuries.
Choice B reason: Stage 3 involves full-thickness loss to subcutaneous tissue, not muscle or bone, unlike the described injury with visible bone (stage 4). Misstaging as 3 underestimates severity, risking inadequate treatments like simple dressings, delaying surgical intervention or infection control critical for deep pressure injuries with bone exposure.
Choice C reason: Stage 1 is intact skin with erythema, not a deep lesion with bone exposure, which is stage 4. Misstaging as 1 grossly underestimates severity, neglecting urgent needs like debridement or antibiotics, risking infection, sepsis, or further tissue loss in severe pressure injuries requiring advanced wound management.
Choice D reason: Stage 2 involves partial-thickness loss with a shallow wound, not deep muscle or bone exposure, as in stage 4. Misstaging as 2 risks inadequate care, like topical treatments instead of surgical intervention, delaying healing and increasing complications like osteomyelitis in severe pressure injuries with visible bone.
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