NCLEX RN Exam Preview Answers - Nurselytic

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Question 1 of 5

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

Correct Answer: B

Rationale: In a situation where a patient is in significant respiratory distress, bilaterally percussing the thorax to note any differences in percussion tones is a crucial nursing intervention. Percussion provides instant feedback regarding changes in underlying tissue density, which can give important clues about the patient's physical status. This hands-on assessment technique is readily available and can be performed promptly. Counting the patient's respirations, while important, may not provide as much detailed information as percussion. Ordering a chest x-ray and waiting for the results can cause a delay in assessing and addressing the patient's immediate needs. Inspecting the thorax for new masses and bleeding, although relevant, may not offer as much real-time information about the patient's condition compared to percussion.

Question 2 of 5

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Question 3 of 5

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Question 5 of 5

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Similar Questions

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?"? Which critique of the nurse's technique is most accurate?
During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality?
The nurse is discussing the term subculture with a student nurse. Which statement by the nurse would best describe subculture?
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

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