Difficulty: Medium
Average Score: 90%
Simulated
A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed with supraclavicular retractions & a respiratory rate of 28. The client states, 'I can't catch my breath when I lay down.' What documentation would be used for this presentation? (SELECT ALL THAT APPLY)
Correct answer
B,C
Rationale
The correct answers are B and C. Choice B, "Tachypnea & dyspnea present," is appropriate because the client is exhibiting a rapid respiratory rate and difficulty breathing. Choice C, "Patient has orthopnea," is also correct as the client experiences shortness of breath when lying down.
Choice A, "Pt has a history of smoking," is incorrect as it does not directly relate to the current respiratory distress. Choice D, "Diaphragmatic breathing in progress," is incorrect as the client is not displaying this specific breathing pattern. Choice E, "Cheyne-Stokes respirations present," is also incorrect as the client's breathing pattern does not align with Cheyne-Stokes respirations.
Choice A, "Pt has a history of smoking," is incorrect as it does not directly relate to the current respiratory distress. Choice D, "Diaphragmatic breathing in progress," is incorrect as the client is not displaying this specific breathing pattern. Choice E, "Cheyne-Stokes respirations present," is also incorrect as the client's breathing pattern does not align with Cheyne-Stokes respirations.