While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?

Vital sign abnormalities.

Presence of peripheral edema.

White blood cell (WBC) count.

Sputum characteristics.

Answer and Explanation

The Correct Answer is D

A.   Vital sign abnormalities can provide critical information about the client's overall condition and help determine if there is an acute or chronic issue that needs to be addressed. While important, this assessment might not provide specific details about the cause of the productive cough.
B.   Peripheral edema is often related to cardiovascular or renal issues and might not be directly related to the cause of a productive cough. While edema can provide information about fluid balance and possible heart failure, it does not directly address the specific characteristics or causes of a cough.
C.   A white blood cell count can help determine if there is an underlying infection or inflammatory process. Elevated WBC levels might indicate an infection, which could be a cause of the productive cough. This test is useful for diagnosing conditions like pneumonia or bronchitis but is not as immediately relevant as assessing the sputum characteristics in understanding the nature of the cough.
D.   The characteristics of sputum (color, consistency, presence of blood, etc.) can provide valuable information about the cause of the productive cough. For instance, yellow or green sputum might suggest a bacterial infection, while clear sputum could be associated with viral infections or allergies.

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Correct Answer is C

Explanation

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.

A. Since this client has only a small area of crepitus, it probably is not a significant finding. B. Crepitus is always abnormal and should be followed-up with a more detailed assessment. C. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately.

Correct Answer is B

Explanation

A. The presence of crepitus, regardless of size, indicates air trapped in the subcutaneous tissue, which can be associated with various conditions including trauma, infection, or underlying lung issues. Therefore, it is important to evaluate the finding further rather than assuming it is insignificant.
B. This is the most accurate interpretation. Crepitus is indeed an abnormal finding and warrants further investigation. Its presence can indicate underlying issues such as subcutaneous emphysema, which may be related to trauma, infections, or other conditions that need to be addressed. A more detailed assessment, including possible imaging or additional diagnostic tests, should be pursued to determine the cause and appropriate management.
C. While it is true that subcutaneous air can be absorbed over time, the presence of crepitus is still an abnormal finding that needs to be evaluated. The underlying cause of the trapped air must be identified, as it may indicate an injury or other health issues that require intervention. Simply assuming that it will resolve on its own without further investigation could overlook a potentially serious condition.
D. While a fractured rib can cause crepitus, this finding alone does not necessarily mean an immediate chest x-ray is required. The decision to order an x-ray should be based on a comprehensive assessment of the client’s symptoms, history, and physical examination findings. Although a rib fracture is a possible cause, other conditions such as subcutaneous emphysema or infections should also be considered.

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While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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