A client comes to the clinic for a physical checkup. A nurse is performing the client's
physical examination. Which of the following are the actions the nurse should perform
during the examination technique of inspection to achieve the best examination? Select
all those that apply. - Answer Ensure adequate light is present.
Use a penlight or lamp to visualize body cavities.
Examine each area for size, shape, color, symmetry, position, and abnormality.
Observe for asymmetry from right to left
A patient is admitted after a motor vehicle accident with multiple fractured ribs. While
assessing the patient's respiratory status, what signs and symptoms of secondary
pneumothorax would the nurse expect to see? Answer Sharp pleuritic pain that worsens
with inspiration.
A client is diagnosed with COPD and is on oxygen therapy through a simple oxygen face
mask. After a while, the blood analysis of the client reveals an abnormal elevation of
carbon dioxide levels. What should be the nurse's first action? - Answer Remove the
mask and use a nasal cannula for oxygen delivery.
Rationale:
Simple face masks are designed to deliver high-flow O2. In COPD patients this causes
hypoventilation. Decreased O2 is the stimulus to breathe with COPD, so excessive O2
destroys the stimulus. The hypoventilation that results causes excessive retention of
carbon dioxide. Also, a patient may inhale exhaled carbon dioxide retained in a mask.
Therefore, masks are contraindicated in patients with COPD.
, When charting a nursing assessment, which of the following lists the correct terms to
describe respirations? - Answer Bradypnea is less than 12 breaths per minute.
Tachypnea is greater than 20 breaths per minute.
Apnea is the absence of respirations for some
While conducting a patient assessment, the nurse notices bluish discoloration of the
skin and mucous membrane. For what condition might the nurse suspect the patient is
at risk? - Answer Hypoxia
Rationale:
Cyanosis is the bluish discoloration of the skin and mucous membrane, a clinical
manifestation of hypoxia or reduced tissue oxygenation.
A patient comes to the clinic for a routine check-up. The nurse is to conduct a physical
examination of the patient. What is the appropriate nursing intervention the nurse
should implement during the examination by palpation? Warm the hands and proceed
with a light touch.
A patient with COPD is receiving oxygen at a rate of 2 L/min. The patient experiences
dyspnea when in the supine position during a bath. What is the best initial nursing
action?
A. Increase the oxygen flow rate
B. Perform tracheal suctioning
C. Notify the health care provider
D. Place the patient in semi-Fowler's position. -Answer D. Place the patient in
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