While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths/minute. Which action should the nurse implement?

Auscultate all lobes of the client's lungs.

Place the client in low Fowler's position.

Administer a respiratory aerosol treatment.

Provide oxygen at 2 L/minute via face mask.

Answer and Explanation

The Correct Answer is C

A.   Auscultating all lobes of the lungs is an important step in a comprehensive respiratory assessment. It helps the nurse assess the presence and distribution of abnormal breath sounds, such as wheezing, and evaluate the overall condition of the lungs. While this is a crucial part of the assessment process, it is more of a diagnostic step rather than an immediate intervention for managing respiratory distress.
B.   Placing the client in a low Fowler's position (45 degrees) can help improve ventilation and comfort, especially if they are experiencing difficulty breathing. However, in the context of audible wheezing and elevated respiratory rate, more immediate interventions to address the underlying issue are typically required.
C.   Administering a respiratory aerosol treatment (such as a bronchodilator) is a direct intervention to address wheezing, which is often caused by bronchoconstriction or inflammation. Aerosol treatments can help open the airways and relieve wheezing, making this a priority action for managing the symptoms described.
D.   Providing supplemental oxygen can be beneficial if the client is experiencing hypoxia (low blood oxygen levels). However, the need for oxygen should be determined based on the client's oxygen saturation levels and overall clinical picture. While oxygen can support breathing, it does not address the underlying cause of wheezing or the elevated respiratory rate directly.

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Correct Answer is A

Explanation

A. Nailbed clubbing is characterized by an increased angle between the nail and the nailbed, typically greater than 180 degrees. An angle of 200 degrees is consistent with clubbing, which can be a sign of chronic respiratory or cardiovascular conditions, such as chronic lung diseases, congenital heart defects, or other systemic conditions.
B. Consulting with a podiatrist to trim toenails is important for foot care but is not directly related to the finding of nailbed clubbing. The angle of the nailbed is more indicative of a systemic issue rather than a local foot care problem. Therefore, this action does not address the underlying concern suggested by the angle of 200 degrees.
C. While anemia or other blood conditions can affect the nails, the specific finding of a nailbed angle of 200 degrees is more indicative of clubbing rather than issues typically associated with hemoglobin levels. Therefore, while monitoring hemoglobin is important for overall health, it is not the immediate priority in response to the finding of nailbed clubbing.
D. Administering oxygen might be necessary if the client is experiencing symptoms of hypoxia or has a condition affecting oxygenation. However, the finding of nailbed clubbing itself does not immediately necessitate oxygen therapy. Oxygen administration should be based on specific symptoms or clinical indications of hypoxia rather than the nailbed angle alone.

A. Inspection. B. Percussion. C. Palpation. D. Auscultation.

Correct Answer is A

Explanation

A. In the context of detecting papilledema, "inspection" refers to using an ophthalmoscope to examine the optic disc for swelling. Papilledema, which is swelling of the optic disc due to increased intracranial pressure, can only be observed through this direct examination of the eye’s interior. This technique is the most appropriate and accurate for confirming papilledema as it allows the nurse to visually inspect the optic disc for signs of swelling or other abnormalities.
B. Percussion involves tapping on the body to assess underlying structures and is commonly used in evaluating lung and abdominal sounds. It is not used for assessing the optic nerve or papilledema. Therefore, percussion is not relevant for confirming the presence of papilledema.
C. Palpation involves feeling the body’s surface to assess for abnormalities such as swelling or
tenderness. It is used for evaluating various parts of the body but does not apply to detecting papilledema. Papilledema involves changes to the optic nerve head, which cannot be assessed through palpation.
D. Auscultation involves listening to internal body sounds using a stethoscope, such as heartbeats, lung sounds, or abdominal sounds. This technique is not used to assess the optic disc or detect papilledema. It is not relevant for the diagnosis of conditions affecting the optic nerve.

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While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths/minute. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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