A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?
The client has a respiratory rate of 28 breaths per minute.
The client has a temperature of 38°C (100.4°F).
The client has a blood pressure of 140/90 mmHg.
The client has a heart rate of 90 beats per minute.
The Correct Answer is A
Choice A rationale
A respiratory rate of 28 breaths per minute indicates tachypnea, which is a sign of respiratory distress. Immediate intervention is needed to address the underlying cause and prevent further deterioration of the patient’s condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which may suggest an infection. While this requires medical attention, it is not as immediately critical as respiratory distress.
Choice C rationale
A blood pressure of 140/90 mmHg is considered high, but it does not indicate an immediate need for intervention in the context of COPD. Hypertension should be managed, but it is not an acute emergency.
Choice D rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate an immediate need for intervention. Monitoring the patient’s heart rate is important, but it is not an urgent concern in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Meningitis presents with fever, stiff neck, and photophobia. It is an inflammation of the membranes surrounding the brain and spinal cord, often caused by infection.
Choice B rationale
Encephalitis involves inflammation of the brain itself, presenting with fever, headache, and altered mental status, but not specifically photophobia.
Choice C rationale
Migraine can cause photophobia and headache but is not typically associated with fever and stiff neck.
Choice D rationale
Sinusitis can cause fever and headache but not typically photophobia and stiff neck.
Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 28 breaths per minute indicates tachypnea, which is a sign of respiratory distress. Immediate intervention is needed to address the underlying cause and prevent further deterioration of the patient’s condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which may suggest an infection. While this requires medical attention, it is not as immediately critical as respiratory distress.
Choice C rationale
A blood pressure of 140/90 mmHg is considered high, but it does not indicate an immediate need for intervention in the context of COPD. Hypertension should be managed, but it is not an acute emergency.
Choice D rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate an immediate need for intervention. Monitoring the patient’s heart rate is important, but it is not an urgent concern in this scenario.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.