Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?
"I would palpate, inspect, percuss, and the auscultate.”
"I would percuss, palpate, auscultate, and then inspect.”
"I would auscultate, inspect, percuss, and then palpate."
"I would inspect, auscultate, palpate, and then percuss."
"I would inspect, palpate, percuss, then auscultate.”
The Correct Answer is E
A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.
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Correct Answer is E
Explanation
A. In asthma, increased airway resistance can lead to decreased fremitus due to air trapping and poor conduction of vibrations.
B. Emphysema results in hyperinflated lungs, which typically decreases tactile fremitus because of increased air in the alveoli.
C. Pneumothorax involves air in the pleural space, leading to decreased tactile fremitus as well, since air does not conduct vibrations well.
D. Acute bronchitis can cause some changes in fremitus, but it typically does not significantly increase it.
E. Pneumonia causes consolidation of lung tissue, which increases tactile fremitus due to enhanced transmission of vibrations through solidified lung tissue.
Correct Answer is C
Explanation
A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.