Which respiratory assessment finding will most likely indicate the client is exhibiting asthma?

respiratory wheezing

normal breath sounds

lung sounds clear to auscultation

decreased respiratory rate

Answer and Explanation

The Correct Answer is A

A.   Wheezing is a high-pitched, musical sound produced by narrowed airways. It is a common and classic finding in asthma due to the bronchoconstriction that occurs during an asthma exacerbation. The presence of wheezing on auscultation is a strong indicator of asthma, as it reflects the turbulent airflow through constricted bronchi.
B.   Normal breath sounds would generally not indicate asthma. In the absence of an asthma attack or during periods of remission, a person with asthma might have normal breath sounds. However, during an asthma exacerbation, the breath sounds are more likely to be abnormal, such as wheezing or decreased breath sounds if airflow is severely compromised.
C.   Clear lung sounds on auscultation would typically indicate that there are no abnormal sounds such as wheezes, crackles, or rhonchi. In the context of asthma, clear lung sounds could be heard if the asthma is well-controlled or if the client is not currently experiencing an exacerbation.
D.   A decreased respiratory rate (bradypnea) is not a typical finding in asthma. During an asthma exacerbation, clients often experience tachypnea (increased respiratory rate) due to difficulty breathing and the increased effort required to breathe.

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Correct Answer is ["A","B","D"]

Explanation

A. Assessing the client’s respirations is crucial in evaluating their respiratory status. This includes
checking the rate, rhythm, depth, and effort of breathing. Given the client’s symptoms of cough and lung congestion, it's important to assess whether there are any signs of respiratory distress or abnormal breathing patterns.
B. Auscultating lung sounds is essential to identify any abnormal lung sounds such as wheezes, crackles, or rhonchi. This helps in evaluating the presence and severity of lung congestion and can provide insights into the underlying cause of the client's symptoms.
C. While assessing peripheral pulses is important in a comprehensive cardiovascular assessment, it is not directly related to evaluating symptoms of a cold, cough, or lung congestion. The focus of the assessment for these specific symptoms would be more on the respiratory system.
D. Checking the client’s temperature is important because a fever may indicate an infection or inflammation, which can be associated with the symptoms of a cold or lung congestion. This helps in assessing the overall systemic response to the infection.
E. A musculoskeletal and neurological examination is not directly relevant to assessing symptoms related to a cold, cough, or lung congestion. These exams are more appropriate for evaluating physical function and neurological status, which are not the primary concerns in this scenario.
F. While family history can provide valuable context for some conditions, it is not the immediate focus for evaluating current symptoms like a cold, cough, or lung congestion. The priority should be on the present symptoms and their immediate effects on the client’s health.

A. The client sitting up and leaning over the bedside table, B. Fine bilateral basilar crackles. C. A respiratory rate of 9 breaths/min. D. A large barrel chest.

Correct Answer is C

Explanation

A. This position is often seen in clients with chronic respiratory conditions like emphysema. It is called the tripod position and can help the client breathe more easily by expanding the chest and reducing the work of breathing. While this position indicates the client is experiencing difficulty breathing, it is not an immediate emergency but rather a sign of their chronic respiratory condition.

B. Fine crackles (or rales) are abnormal lung sounds that can indicate fluid in the alveoli. In emphysema, crackles are not typical and may suggest a complication such as pulmonary edema or infection.
However, if these crackles are not severe and the client’s overall condition is stable, it may not be the
most urgent issue compared to other findings.
C. A respiratory rate of 9 breaths per minute is considered bradypnea, which is significantly lower than the normal range (12-20 breaths/min). For a client with chronic emphysema on oxygen therapy, bradypnea is a concerning finding because it indicates inadequate respiratory drive and potential respiratory depression.
D. A barrel chest is a common physical finding in clients with chronic emphysema due to chronic air trapping and lung overexpansion. It reflects long-standing changes in the chest structure due to the disease. While it is a notable finding, it is a chronic manifestation of emphysema and not an immediate concern in the context of acute clinical status.

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Which respiratory assessment finding will most likely indicate the client is exhibiting asthma?

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Naxlex Comprehensive Predictor Exams

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which assessments should the nurse include for this focused assessment? Select the three options that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is evaluating and assessing a client with a diagnosis of chronic emphysema. The client is receiving oxygen therapy at a flow rate of 5 L/min via nasal cannula. Which findings concern the nurse immediately?

Correct Answer is C

Explanation

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