The nurse is assessing a client with asthma. Scattered wheezes are noted, and the client's oxygen saturation is 88%. What other assessments are essential for the nurse to perform? (Select all that apply.)
a. Assess for accessory muscle use.
b. Assess anterior-posterior diameter.
c. Assess inspiration/expiration ratios.
d. Assess the suprasternal notch.
e. Perform a stress test.
f. Assess a chest x-ray.
g. Assess mucous membranes.
A, C, D, G
Accessory muscle use may help the client breathe during an attack. Muscle retraction may be seen at the sternum and at the suprasternal notch. Mucous membranes can also tell the nurse about oxygenation. Inspiration versus expiration can tell the nurse how the client is breathing. The anterior-posterior diameter gives indication of a chronic condition; assessing this during an attack will not help the client. Likewise, performing a stress test and a chest x-ray during an attack would not be beneficial.
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