Practice Question
The nurse assesses a client admitted with stage 4 lung cancer reporting difficulty breathing. What additional finding should the nurse identify as most concerning?
Answer Choices:
Correct Answer:
Intercostal retractions on inspiration
Rationale:
🟦 Intercostal retractions indicate that the client is working extremely hard to breathe, showing significant respiratory muscle fatigue and an inability to maintain adequate ventilation.
🟦 Retractions occur when the negative intrathoracic pressure becomes so strong that the soft tissues between the ribs pull inward, signaling impending respiratory failure.
🟦 In a client with advanced stage 4 lung cancer, this finding is especially concerning because it suggests airway obstruction, decreased lung expansion, or increased pressure on lung tissues from tumor burden.
🟦 Retractions are an acute sign that gas exchange is compromised and that oxygenation may rapidly decline without immediate intervention.
🟦 This finding is more concerning than changes in heart rate or blood pressure because it reflects mechanical difficulty moving air, not just a physiological response to stress.
🟦 Prompt nursing response is required because retractions can precede respiratory arrest, especially in weakened clients.
🟦 Therefore, intercostal retractions represent the most urgent and dangerous finding for this patient with known respiratory compromise.
❌ Incorrect Answers
Heart rate of 107 beats per minute
❌ A heart rate of 107 bpm represents mild tachycardia, which is expected in clients experiencing pain, stress, or respiratory difficulty.
❌ While important to monitor, it does not indicate an immediate threat of respiratory failure compared to retractions.
Client report of experiencing anxiety
❌ Anxiety is a common subjective response to dyspnea and is not a direct indicator of respiratory collapse.
❌ The cause of the anxiety must be assessed, but it is not as clinically urgent as objective signs of respiratory distress.
Blood pressure of 142/88 mm Hg
❌ This blood pressure is slightly elevated but does not pose an acute threat and is often related to stress or discomfort.
❌ It does not indicate impaired ventilation or immediate deterioration of respiratory status.
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This question is from W4 NR324 NR329 Exam which contains 49 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 4