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
Autonomic neuropathy is a common complication of diabetes and can affect various autonomic functions, including heart rate, blood pressure, and digestion. It is caused by damage to the autonomic nerves due to prolonged high blood sugar levels.
Choice B rationale
Diabetic-induced leukocyte depletion is not a recognized complication of diabetes. Diabetes primarily affects blood vessels and nerves rather than causing leukocyte depletion.
Choice C rationale
Diabetic-induced angiopathy refers to damage to blood vessels caused by diabetes. While it is a recognized complication, autonomic neuropathy is more directly related to diabetic-induced complications.
Choice D rationale
Overdrive of the RAAS (renin-angiotensin-aldosterone system) is not a specific complication of diabetes. While diabetes can affect the RAAS, it is not the most likely condition related to diabetic-induced complications.
Correct Answer is B
Explanation
Choice A rationale
Nausea and vomiting can be caused by various conditions, including gastrointestinal issues and brain injuries, but they are not specifically indicative of a diffuse brain stem injury.
Choice B rationale
Nuchal rigidity, or neck stiffness, is a classic sign of meningeal irritation, often due to meningeal edema in conditions like meningitis.
Choice C rationale
Bilateral fixed and dilated pupils are more commonly associated with severe brain injury or increased intracranial pressure, not specifically a cerebellar brain attack.
Choice D rationale
Brudzinski’s sign is a physical exam finding indicative of meningeal irritation, commonly seen in bacterial meningitis, not specifically viral meningitis.
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