The nurse had planned to conduct a patient interview regarding pulmonary history

Question

Which patient behaviors would indicate to the nurse that this interview should be delayed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient cannot speak in complete sentences.
2. The patient is sitting up at the bedside.
3. The patient's respiratory rate has increased from 14 to 20.
4. The patient has assumed a forward leaning posture, braced on the hands.
5. The patient's arterial blood gases reveal a pH of 7.38.

Answer 1

1,3,4
Rationale 1: The patient who cannot speak in complete sentences may be suffering from respiratory distress. The nurse should delay the interview and should conduct further physical assessment.
Rationale 2: Finding the patient sitting up at the bedside is not a reason to delay the interview unless other, more specific, assessments are also made.
Rationale 3: An increase in respiratory rate may indicate respiratory distress. The nurse should delay the interview and conduct additional physical assessment.
Rationale 4: This position is called the "tripod" position and is a classic maneuver to expand lung fields. The patient may be in acute respiratory distress, so the interview should be delayed.
Rationale 5: This is a normal arterial blood gas reading and does not indicate respiratory compromise.