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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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Free Nursing Study Resources

Correct Answer is C

Explanation

C. A bed alarm is a device that triggers an alert when the client attempts to get out of bed or leaves a designated area. Bed alarms can be effective in alerting nursing staff to the client's movements, allowing for timely intervention to prevent wandering and ensure the client's safety. This intervention is commonly used in healthcare settings to monitor clients at risk for falls or wandering.

A Moving the client to a double room may not necessarily prevent wandering. In fact, it could potentially increase the risk if the client wanders into another resident's space or attempts to leave the room altogether.

B. Using chemical restraints (such as medications to sedate or calm the client) is not recommended unless absolutely necessary for the safety of the client or others. It does not address the underlying cause of wandering and can have significant adverse effects on the client's health and well-being.

D. Providing excessive stimulation can overwhelm and agitate clients with dementia, potentially worsening behaviors such as wandering. It is important to offer activities that are calming, engaging, and appropriate for the client's cognitive abilities.

A. Administer opioids PO. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Check the client's blood pressure every 8 hr.

Correct Answer is C

Explanation

C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.

A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.

B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.

D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

Correct Answer is C

Explanation

A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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