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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Septic shock is a severe infection leading to systemic inflammation, characterized by high fever (39°C), low blood pressure (90/60 mmHg), and signs of organ dysfunction. It is a medical emergency requiring immediate intervention.
Choice B rationale
Cardiogenic shock is caused by the heart’s inability to pump blood effectively, leading to hypotension and signs of poor perfusion, but not necessarily high fever.
Choice C rationale
Neurogenic shock results from a disruption in the autonomic pathways, leading to hypotension and bradycardia, but not high fever.
Choice D rationale
Anaphylactic shock is a severe allergic reaction causing hypotension, respiratory distress, and other symptoms, but not typically high fever.
Correct Answer is B
Explanation
Choice A rationale
Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.
Choice B rationale
Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.
Choice C rationale
Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.
Choice D rationale
Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.
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