A nurse is caring for a client who has COPD.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should administer a total 1320ml sodium chloride in the first hour, 880ml each subsequent hour.
Rationale
First Hour Administration
Rate: 15 ml/kg/hr Client's weight: 88 kg
Calculation: 15 ml/kg/hr × 88 kg= 1320ml/hr
Therefore, in the first hour, the nurse should administer 1320 mL of 0.9% sodium chloride.
Subsequent Hour Administration
Rate: 10 ml/kg/hr Client's weight: 88 kg
Calculation: 10 ml/kg/hr × 88kg= 880mls
Therefore, each subsequent hour after the first, the nurse should administer 880 mL of 0.9% sodium chloride.
Correct Answer is D
Explanation
D. Morphine is effective in reducing anxiety due to its sedative and anxiolytic properties. Decreased anxiety can be an indication that morphine is effective in managing symptoms associated with acute heart failure, such as dyspnea and anxiety related to difficulty breathing.
A Morphine is a potent opioid analgesic that can depress the respiratory center, leading to decreased respiratory rate or even respiratory depression in some cases.
B. Vomiting after morphine administration does not indicate effectiveness of the medication in managing acute heart failure symptoms. It is rather a side effect that needs to be managed.
C. Decreased urinary output is not a sign of effectiveness in managing acute heart failure symptoms. It is an adverse effect that needs to be monitored and managed separately.
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