Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited.
Correct Answer: C. The client’s oxygen saturation is 97%.
Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.
Option A: A thorough respiratory assessment consists of inspection, palpation, percussion, and auscultation in conjunction with a comprehensive health history. Use a systematic approach and compare findings between left and right so the patient serves as his own control.
Option B: Respirations should be even, unlabored, and regular at a rate of 12 to 20 breaths per minute. Normally, inspiration is half as long as expiration, and chest expansion is symmetrical. If the client appears anxious or exhibits nasal flaring, cyanosis of the lips and mouth, intercostal retraction, or use of accessory muscles of respiration, he may be in respiratory distress.
Option D: Normally, the thorax is symmetrical and the anterior-posterior diameter is less than the transverse diameter. (Equal diameters may signal chronic obstructive pulmonary disease in an adult.) Note any structural deformity such as a pigeon chest (pectus carinatum) or funnel chest (pectus excavatum).
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