You are examining a client with respiratory distress. Which physical assessment would best determine if the client has acute hypoxemia?
Inspect the nailbeds for the presence of clubbing.
Inspect the nailbeds and mucous membranes for the presence of cyanosis.
Palpate for areas of decreased tactile fremitus.
Auscultate for the presence of any adventitious breath sounds.
The Correct Answer is B
A. Clubbing is a sign of chronic hypoxia, not acute hypoxemia.
B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an indicator of acute hypoxemia.
C. Palpating for decreased tactile fremitus is related to fluid or air in the lungs, not specifically hypoxemia.
D. Auscultation for adventitious breath sounds can reveal respiratory issues but does not directly confirm hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct response because it educates the client on the fact that many sore throats are viral in origin and antibiotics, which treat bacterial infections, would not be effective in such cases. Overuse of antibiotics can also contribute to antibiotic resistance.
B. Asking the client to bring the bottle of antibiotics does not address the misuse of the medication.
C. This statement is incorrect as streptococcal infections often involve fever.
D. A throat culture would help confirm the cause of the sore throat, and antibiotics should not be taken without proper diagnosis.
Correct Answer is D
Explanation
A. Recommending a psychiatric consult is premature and not appropriate for routine anxiety during an assessment.
B. Starting with invasive aspects may increase the client's anxiety. Instead, the nurse should ease the client into the exam.
C. Staying with the client at all times may not be necessary and could make the client feel more uncomfortable.
D. Using a relaxed manner and reassuring the client can help reduce anxiety and make the physical assessment more comfortable.
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