The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?
Decreased lung sounds on expiration
Respirations are 40 breaths/minute
Anterior-posterior diameter ratio is 1:1
Hyperresonance is noted to percussion
Decreased tactile fremitus is present
The Correct Answer is B
A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.
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Correct Answer is C
Explanation
A. Asthma typically presents with wheezing, not fine crackles.
B. Pneumothorax usually presents with decreased or absent breath sounds rather than crackles.
C. Atelectasis, which is common after surgery, can cause fine crackles at the lung bases due to collapsed alveoli reopening during inspiration.
D. Emphysema generally results in diminished breath sounds and hyper-resonance rather than crackles.
E. Bronchitis typically produces coarse crackles or rhonchi, not fine crackles.
Correct Answer is B
Explanation
A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.