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.

Answer and Explanation

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.

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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.

A. The hypokalemia brought on severe muscle spasms, causing exhaustion. B. Due to his low potassium, his cells rely on glycolysis. C. Due to the hypokalemia, his cells are hyperpolarized. D. The hypernatremia caused cellular dehydration, leading to lethargy.

Correct Answer is D

Explanation

Choice A rationale
Hypokalemia can cause muscle weakness and cramps, but it does not typically lead to severe muscle spasms causing exhaustion. The patient’s symptoms of lethargy and weakness are more likely related to electrolyte imbalances and dehydration rather than muscle spasms.
Choice B rationale
While low potassium levels can affect cellular metabolism, the primary issue here is not glycolysis. The patient’s symptoms are more consistent with dehydration and electrolyte imbalances rather than a metabolic shift to glycolysis.
Choice C rationale
Hypokalemia can cause cells to become hyperpolarized, leading to muscle weakness and decreased reflexes. However, the patient’s symptoms of lethargy and weakness are more likely due to dehydration and electrolyte imbalances rather than cellular hyperpolarization.
Choice D rationale
Hypernatremia, or high sodium levels, can cause cellular dehydration, leading to symptoms such as lethargy and weakness. The patient’s lab results and clinical presentation are consistent with hypernatremia-induced cellular dehydration, which explains his symptoms.

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A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD) who presents with increased shortness of breath and a productive cough. Which of the following findings would indicate a potential exacerbation of COPD?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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