A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
Weight gain
Decrease in anteroposterior diameter of the chest
HCO3 24 mEq/L
pH 7.31
The Correct Answer is D
pH 7.31
Rationale:
A - This is incorrect because weight gain is not expected in clients who have COPD, as they often have difficulty eating and digesting food due to dyspnea and fatigue.
B - This is incorrect because a decrease in anteroposterior diameter of the chest is not typical of COPD, as the condition causes hyperinflation and air trapping in the lungs, leading to an increase in chest size and a barrel-shaped appearance.
C - This is incorrect because HCO3 24 mEq/L is within the normal range for blood bicarbonate levels, which are 22 to 26 mEq/L. Clients who have COPD often have chronic respiratory acidosis, which stimulates the kidneys to retain bicarbonate and increase its levels in the blood to compensate for the low pH.
D - This is correct because pH 7.31 indicates acidosis, which is common in clients who have COPD due to impaired gas exchange and accumulation of carbon dioxide in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.
- B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.
- C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.
- D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.
Correct Answer is B
Explanation
Choice A rationale:
Shellfish allergies are not a contraindication to receiving the influenza vaccine. The vaccine contains no shellfish-derived ingredients.
Choice B rationale:
Egg allergies are a contraindication to receiving the influenza vaccine. Traditionally, most influenza vaccines are prepared using eggs and can provoke allergic reactions in individuals allergic to eggs. However, individuals with a mild egg allergy can often receive the vaccine under medical supervision. It is crucial to assess the severity of the egg allergy and consult with an allergist or immunologist before administering the vaccine.
Choice C rationale:
Gelatin allergies are generally not a contraindication to receiving the influenza vaccine. While some vaccines contain gelatin, it is not a component of all influenza vaccines. If the specific vaccine being administered contains gelatin, it should be avoided in individuals with a gelatin allergy.
Choice D rationale:
Milk allergies are not a contraindication to receiving the influenza vaccine. Milk or dairy products are not typically included in the influenza vaccine formulation.
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