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A nurse is caring for a client who has been admitted with chronic obstructive pulmonary disease.

Exhibits
Select the 4 priority findings that require immediate follow-up.

Barrel chest

Shortness of breath

Arterial blood gas results

Electrocardiogram results

Oxygen saturation

Lung sounds

Answer and Explanation

Correct Answer : B,C,D,E

A. Barrel chest
Common chronic COPD finding, not acute or emergent.

B. Shortness of breath
Indicates respiratory compromise that is worsening-urgent.

C. Arterial blood gas results
Indicates respiratory acidosis; pCO₂ is severely elevated.

D. Electrocardiogram results
Needed to assess for cardiac complications due to hypoxia and acidosis.

E. Oxygen saturation
O₂ sat of 83% on room air is critically low and requires intervention.

F. Lung sounds
Wheezing is expected with COPD; less urgent than ABGs or O₂ sat.

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Correct Answer is B

Explanation

A. Mental status assessment
Mental status assessments evaluate cognition, mood, orientation—not environmental hazards.

B. Environmental health assessment
This type of question evaluates potential environmental risks, such as toxins or pollutants. Correct.

C. Faith-based assessment
This involves spiritual beliefs, not chemical exposures.

D. Nutritional assessment
Nutritional assessments focus on diet, weight, and nutritional intake, not exposure to toxins.

A. "I should breathe deeply." B. "I should cough frequently." C. "I should avoid pain medications as much as possible." D. "I should use an incentive spirometer regularly."

Correct Answer is C

Explanation

A. "I should breathe deeply."
Deep breathing prevents atelectasis and promotes gas exchange.

B. "I should cough frequently."
Frequent coughing helps clear secretions and prevent pneumonia.

C. "I should avoid pain medications as much as possible."
This is incorrect. Adequate pain control is essential for effective breathing and coughing. Pain medications should not be avoided without cause.

D. "I should use an incentive spirometer regularly."
Incentive spirometry is essential to prevent respiratory complications.

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A nurse is caring for a client who has been admitted with chronic obstructive pulmonary disease. Exhibits Select the 4 priority findings that require immediate follow-up.

Nursing Test Bank

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A nurse is caring for a client who has been admitted with chronic obstructive pulmonary disease.

Exhibits
Select the 4 priority findings that require immediate follow-up.