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 ["A","B","E"]
Explanation
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B. Smoking contributes to hypercoagulability and vascular damage, both of which elevate the risk of clot formation in veins.
C. A history of stomach ulcers is not directly associated with an increased risk of blood clots; rather, it pertains more to gastrointestinal health.
D. Overhydration generally does not increase the risk of blood clots; rather, maintaining adequate hydration is important for circulation.
E. Taking birth control pills can increase the risk of blood clots due to hormonal changes that promote hypercoagulability.
Correct Answer is B
Explanation
A. This option incorrectly includes the aortic valve rather than the tricuspid valve in the S1 heart sound.
B. S1 represents the closure of the mitral and tricuspid valves, which occurs at the beginning of ventricular systole and produces the "lub" sound.
C. The pulmonic valve closure is associated with the S2 heart sound, not S1.
D. The closure of the pulmonic and aortic valves occurs in S2, not S1.
E. This combination is incorrect, as S1 is associated with mitral and tricuspid valve closure.