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 C
Explanation
C. The CPM machine should be used during designated therapy sessions as prescribed by the healthcare provider. Turning it off during meals allows the client to focus on eating without interference from the machine.
A The range of motion settings on the CPM machine should be adjusted gradually according to the client's tolerance and prescribed therapy plan. Rapidly increasing the range of motion could cause discomfort, pain, or even injury to the client's knee joint. Therefore, the nurse should not increase the range of motion rapidly.
B Storing the CPM machine on the floor is not ideal because it can increase the risk of contamination or damage to the equipment. The machine should be stored on a clean, stable surface when not in use to prevent accidental damage or exposure to dirt and debris.
D. Regular checks of the CPM machine's settings are important, but every 12 hours may not be frequent enough to ensure the machine is functioning correctly and safely.
Correct Answer is D
Explanation
D. After inhaling the medication, holding the breath for about 10 seconds allows the medication to settle in the lungs and be absorbed effectively into the bloodstream. This improves the medication's effectiveness in controlling asthma symptoms.
A Waiting 30 seconds between puffs is not a standard instruction; instead, it is generally advised to wait about one minute between puffs if multiple doses are needed.
B. The whistling sound may indicate that the client is inhaling too quickly or forcefully, which can prevent the medication from reaching the lungs effectively.
C. Cleaning the spacer is also crucial, but it is typically recommended to use warm soapy water rather than cold water, and it should be left to air dry.
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