Respiratory escalation
Question
During a routine adult respiratory check, the nurse sorts actions for independent findings. Which response belongs with each finding?
Continue routine assessment
- Continue the check when chest expansion is even
- Continue the check when the breathing rhythm is regular
Report immediately
- Immediately report worsening shortness of breath
- Immediately report a new decrease in consciousness
Answer
Continue routine assessment: Continue the check when chest expansion is even; Continue the check when the breathing rhythm is regular · Report immediately: Immediately report worsening shortness of breath; Immediately report a new decrease in consciousness
Rationale
An even breathing pattern and symmetric chest movement fit routine assessment findings. Worsening breathing difficulty or a decline in consciousness needs immediate escalation.
Sources
Sources marked “Adapted from” are licensed under CC BY 4.0. We changed the material: its facts are rewritten into an original question, answer options and rationale. The original authors and publishers do not endorse SwipeExam.
- Adapted from Open RN Nursing Skills, 2nd edition: Chapter 10 Respiratory Assessment
- Adapted from Open RN Health Alterations: Chapter 6 Respiratory Alterations
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