A nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings is most concerning?
The client has a respiratory rate of 22 breaths per minute.
The client has a temperature of 38°C (100.4°F).
The client has a pulse oximetry reading of 88%.
The client has a blood pressure of 140/90 mmHg.
The Correct Answer is C
Choice A rationale
A respiratory rate of 22 breaths per minute is slightly elevated but not necessarily concerning for a client with COPD. COPD patients often have higher respiratory rates due to their chronic lung condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which could be a sign of infection. However, it is not the most concerning finding in a COPD patient.
Choice C rationale
A pulse oximetry reading of 88% is concerning because it indicates hypoxemia. COPD patients often have lower oxygen levels, but a reading below 90% is worrisome and may require supplemental oxygen or other interventions.
Choice D rationale
A blood pressure of 140/90 mmHg is elevated but not immediately concerning in the context of COPD. It is important to monitor, but it is not the most critical finding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Decreased breath sounds in the lower lobes can indicate areas of the lung that are not ventilating well, but this finding alone does not specifically indicate an exacerbation of COPD. It could be due to other conditions such as pleural effusion or atelectasis.
Choice B rationale
Increased respiratory rate and use of accessory muscles are signs of respiratory distress and indicate that the patient is working harder to breathe. These findings are consistent with an exacerbation of COPD, where the airways are more obstructed, and the patient has difficulty maintaining adequate ventilation.
Choice C rationale
Elevated blood pressure and heart rate can occur in many conditions and are not specific indicators of a COPD exacerbation. These vital sign changes can be due to pain, anxiety, or other stressors.
Choice D rationale
Presence of wheezing and cyanosis are also indicators of a COPD exacerbation. Wheezing indicates airway obstruction, and cyanosis indicates hypoxemia, both of which are common during an exacerbation.
Correct Answer is A
Explanation
Choice A rationale
Elevated serum levels of troponin indicate cardiac cellular injury or death. Troponin is a protein released into the bloodstream when heart muscle cells are damaged, such as during a myocardial infarction.
Choice B rationale
Sustained glycogenolysis does not cause elevated troponin levels. Glycogenolysis is the breakdown of glycogen to glucose, primarily occurring in the liver and muscles, not related to troponin release.
Choice C rationale
Acute tubular necrosis does not elevate troponin levels. This condition affects the renal tubules and is typically indicated by elevated creatinine and BUN levels.
Choice D rationale
Troponin is not an acute phase reactant. Acute phase reactants are proteins whose levels change in response to inflammation, such as C-reactive protein (CRP), not troponin.
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