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 E
Explanation
A. Providing care based on predetermined criteria may not be responsive to the unique cultural needs of each client.
B. Focusing solely on hospital unit workflow prioritizes efficiency over individualized patient care, which may not respect cultural differences.
C. This approach fails to acknowledge the diverse values and beliefs of clients, which can lead to miscommunication and unmet needs.
D. This implies a top-down approach to care, which may disregard the client’s preferences and cultural context.
E. Honoring the client's differences and perspectives demonstrates the nurse's commitment to culturally responsive care, ensuring that care is tailored to meet the unique needs of each client.
Correct Answer is E
Explanation
A. Normal sounds against the sternum would not be low-pitched or soft; they would typically be more pronounced.
B. Bronchovesicular sounds are medium-pitched and are not expected in the lower lobes; they are usually heard in the central area.
C. Bronchial sounds are high-pitched and hollow, typically heard over the trachea, not in the lower lobes.
D. Normal sounds over the trachea would not be described as low-pitched or soft.
E. Vesicular breath sounds are soft, low-pitched, and normal over peripheral lung fields, including the lower lobes, making this the correct interpretation.