A nurse in the med-surgical ICU is evaluating a patient with a diagnosis of chronic copd. The patient is receiving oxygen at a flow rate of 10 L/min via facemask. Which finding would concern the nurse to act immediately?

Respiratory rate of 8 bpm

A large barrel chest

Fine crackles

The patient assumes the orthopenic position

Answer and Explanation

The Correct Answer is A

A) Respiratory rate of 8 bpm:
This a sign of respiratory depression, which can occur in patients with chronic obstructive pulmonary disease (COPD) who are receiving high-flow oxygen. In COPD patients, particularly those with chronic hypercapnia (elevated carbon dioxide), the body may become less sensitive to CO2 buildup and more reliant on low oxygen levels to trigger the respiratory drive. If oxygen is administered at high flow rate, it can reduce the stimulus for breathing, leading to hypoventilation or even respiratory arrest.

B) A large barrel chest:
A barrel chest is a common physical finding in patients with chronic COPD due to the hyperinflation of the lungs. This is a result of air trapping, which is a hallmark of COPD. While it indicates the long-term effects of COPD, it does not require immediate intervention. It is a chronic sign and not an acute or urgent concern unless accompanied by other signs of acute respiratory distress.

C) Fine crackles:
Fine crackles (or rales) on auscultation can be indicative of fluid in the lungs and may suggest conditions such as pulmonary edema, heart failure, or pneumonia. While crackles could be concerning, they are not as immediately life-threatening as a respiratory rate of 8 bpm. In a patient with COPD, crackles might indicate worsening of their condition, possibly due to an infection or fluid overload, but the priority would still be to assess the patient's breathing and ventilation status first.

D) The patient assumes the orthopneic position:
The orthopneic position (sitting upright or leaning forward) is a common way for patients with COPD to relieve shortness of breath. It is a compensatory action to help improve lung expansion and facilitate breathing. While it is a sign of respiratory distress, it is not an immediate emergency. Many COPD patients use this position to cope with chronic difficulty breathing.

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Correct Answer is D

Explanation

A) Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy may be necessary for clients with COPD, but in this case, the primary concern is thick, tenacious bronchial secretions that the client cannot clear. Administering oxygen may be appropriate if the client has low oxygen saturation, but it does not directly address the difficulty in expectorating sputum. The focus should be on hydration and mobilization of secretions, rather than oxygen administration alone.

B) Helping the client select a low-salt diet:
While a low-salt diet is important for clients with conditions like hypertension or heart failure, it is not directly relevant to the issue of tenacious bronchial secretions in COPD. The priority in this scenario is to improve the client’s ability to clear the thick mucus, which is more effectively addressed by hydration rather than dietary changes.

C) Maintaining a semi-Fowler's position as often as possible:
Positioning the client in a semi-Fowler's position can help improve lung expansion and facilitate breathing. It can also reduce the work of breathing and increase comfort. However, while this is a helpful positioning strategy, it is not the most direct intervention to address the client’s difficulty with expectoration. The client’s difficulty with mucus clearance is best addressed with hydration to thin the secretions.

D) Encouraging the client to drink 2 to 3 L of water daily:
Hydration is one of the most important interventions for clients with COPD who have tenacious bronchial secretions. Adequate fluid intake helps to thin mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of not being able to bring up mucus, making it the most appropriate action to take.

A. infuse lipoproteins to restore the myelin sheath. B. remove excess fluid from the blood stream. C. restore protein levels in the blood. D. remove circulating antibodies from the blood stream.

Correct Answer is D

Explanation

A) Infuse lipoproteins to restore the myelin sheath:
Multiple sclerosis (MS) is an autoimmune disease where the immune system attacks the myelin sheath around nerve fibers. Plasmapheresis does not work by infusing lipoproteins to restore the myelin sheath. The treatment's primary goal is to remove harmful substances from the blood that may be contributing to the autoimmune attack, particularly antibodies that target the nervous system, not by restoring the myelin itself.

B) Remove excess fluid from the bloodstream:
Plasmapheresis is a process used to remove certain substances from the plasma, including antibodies and immune complexes that might be exacerbating an autoimmune condition like MS. If the goal were to remove excess fluid, the treatment would be more akin to dialysis or a fluid management procedure, but this is not the case with plasmapheresis.

C) Restore protein levels in the blood:
While plasmapheresis can sometimes lead to a temporary decrease in protein levels due to the removal of plasma, this is not its primary purpose. The primary goal of plasmapheresis in the context of multiple sclerosis is to remove circulating antibodies and other immune-related substances.

D) Remove circulating antibodies from the bloodstream:
Plasmapheresis works by removing circulating antibodies from the bloodstream. In multiple sclerosis, the immune system mistakenly targets the myelin sheath, and plasmapheresis helps to remove the antibodies responsible for this autoimmune response. This can provide temporary relief of symptoms during acute flare-ups of MS by reducing the immune system's attack on the nervous system.

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A nurse in the med-surgical ICU is evaluating a patient with a diagnosis of chronic copd. The patient is receiving oxygen at a flow rate of 10 L/min via facemask. Which finding would concern the nurse to act immediately?

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Correct Answer is D

Explanation

A client with a diagnosis of multiple sclerosis is scheduled to receive plasmapheresis treatments. A nurse explains to the client's spouse that the purpose of plasmapheresis is to:

Correct Answer is D

Explanation

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