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A nurse is caring for a client who has COPD.

Exhibits

Click to highlight the findings below that require immediate follow-up.

Body System Findings

Neurological

Day 1:
Neurological

Client is oriented to person, place, and time. Client is restless. Pupils are reactive to light. Able to move all extremities.

Pulmonary

Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Oxygen saturation 87% on room air.

Cardiovascular Pulse 110/min. +2 pulses in all extremities.

Client is restless

tachypneic, cough is productive

mucous is yellow

Wheezes and crackles

Oxygen saturation 87% on room air

Pulse 110/min

oriented to person, place, and time

Able to move all extremities

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Restlessness can be a sign of inadequate oxygenation to the brain, known as hypoxia. This is particularly concerning in a client with COPD whose oxygen saturation is already low (87% on room air).

These pulmonary findings indicate worsening respiratory distress in a client with COPD. Tachypnea, productive cough with discolored sputum, and abnormal lung sounds (wheezes and crackles) suggest exacerbation of COPD. The oxygen saturation of 87% on room air is below normal (typically 95% or higher), indicating hypoxemia, which requires immediate assessment and intervention to prevent further respiratory compromise.

The elevated heart rate (110/min) may indicate increased workload on the heart due to respiratory distress and hypoxemia.

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Correct Answer is A

Explanation

A This response addresses a potential cause of exercise-induced hypoglycemia. Clients with type 1 diabetes often need to adjust their insulin dose or carbohydrate intake before exercise to prevent hypoglycemia. Asking about insulin adjustment is relevant to assess whether the client took appropriate precautions.

B. While exercise can cause fatigue, feeling diaphoretic, having palpitations, and extreme exhaustion are not normal responses after exercise, especially for someone with type 1 diabetes. This response does not address the potential cause of the symptoms.

C. This response addresses the importance of carbohydrate intake post-exercise to prevent or treat hypoglycemia. It encourages the client to reflect on their dietary choices following exercise, which can impact blood glucose levels.

D. While establishing a routine for exercise is beneficial for managing diabetes, this response does not address the immediate concern of hypoglycemia or provide guidance on managing the client's current symptoms.

A. Anticipate client to be prepped for cardiac catheterization. B. Assist with a continuous heparin infusion. C. Encourage the client to ambulate. D. Anticipate an increased dosage of metoprolol. E. Obtain a prescription for client to be NPO. F. Request a prescription for an antibiotic.

Correct Answer is ["A","B","E"]

Explanation

A. The client presents with symptoms and signs suggestive of acute coronary syndrome, including chest pain, tachycardia, and ECG changes (ST segment elevation and T wave changes). Elevated troponin levels indicate myocardial injury. Cardiac catheterization is typically indicated in acute coronary syndrome to assess coronary artery anatomy and potentially perform interventions like angioplasty or stenting to restore blood flow to the heart muscle.
B. Continuous heparin infusion is commonly used in the management of acute coronary syndrome to prevent further clot formation and stabilize the condition. It helps in reducing the risk of thrombus formation in the coronary arteries, which is crucial in cases of myocardial infarction.
C. Ambulation is generally not recommended during the acute phase of myocardial infarction or unstable angina. The client's symptoms, such as chest pain, shortness of breath, and diaphoresis, indicate ongoing cardiac compromise. Ambulation could potentially worsen the client's condition or lead to adverse events.
D. Metoprolol is a beta-blocker used to reduce heart rate, blood pressure, and myocardial oxygen demand. While it is indicated in acute coronary syndrome to stabilize heart rate and reduce myocardial ischemia, increasing the dosage should be done cautiously and based on the client's response to initial therapy.
E. NPO status is typically indicated for clients undergoing procedures that require sedation or anesthesia, such as cardiac catheterization. It ensures the client's stomach is empty to reduce the risk of aspiration during the procedure. Given the potential need for cardiac catheterization in this client, obtaining a prescription for NPO status would be appropriate to prepare for the procedure and ensure safety.
F. Antibiotics are not routinely indicated in the management of acute coronary syndrome unless there is evidence of concomitant infection or specific clinical indications (e.g., pneumonia). In the absence of signs or symptoms of infection, requesting an antibiotic prescription is not warranted based on the client's current presentation.

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

Exhibits A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?

Correct Answer is ["A","B","E"]

Explanation

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