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","D"]
Explanation
A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.
B. Attending a course does not confirm comprehension or skill.
C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.
D. Listing healthy food choices indicates understanding of dietary education.
E. Nodding does not confirm learning; it may only indicate acknowledgment.
Correct Answer is A
Explanation
A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.