Question

A client presents to the emergency room with difficulty breathing. The nurse performing the assessment expect to find.

A. Rhonhi in the upper lobes that with clear coughing

b. pulse oxygenation rate of 93%

c.Use of accessory abdominal muscles

d.Respiration rate of 22

Answer 1

The provided history suggests that the patient is in respiratory distress. Therefore, the patient is likely to have the following:

c: use of accessory abdominal muscle

1. The abdominal muscles are attached to the lower ribs
2. The contraction of the abdominal muscle pulls the lower ribs downwards.
3. This pushes the diaphragmatic contents upwards
4. This increases the curvature of the diaphragm
5. The diaphragm is now at a mechanical advantage.
6. This action of abdominal muscle only occurs when the patient is in respiratory distress

d: Respiration rate of 22

1. Normal respiratory rate is between 12 - 20 breaths/ min
2. In respiratory distress, there is tachypnea.( i.e. respiratory rate is more than > 20)

Incorrect options

option A - incorrect

1. Rhonchi are continuous, rattling and low pitched sound heard due to bronchospasm
2. They do not go away with coughing
3. They are relieved by bronchodilators.

option b - incorrect

1. A patient in respiratory distress has low oxygen saturation.
2. The blood oxygen saturation should be less than 90%