The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?
Respiratory rate of 20
Vesicular sounds heard in the lung periphery
Capillary refill time of 5 seconds
AP diameter of 1:2
Equal chest expansion
The Correct Answer is C
A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.
B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.
C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.
D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.
E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.
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Correct Answer is B
Explanation
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B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.
Correct Answer is E
Explanation
A. Providing care based on predetermined criteria may overlook individual client needs and cultural nuances.
B. Prioritizing hospital unit workflow may not align with the individual needs of clients.
C. Care aligned with professional healthcare values may not address the specific cultural values and preferences of diverse clients.
D. This approach may dismiss the client's autonomy and unique cultural context.
E. Honoring the client's differences and perspectives indicates a commitment to culturally responsive care, recognizing and respecting diverse backgrounds.