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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 D

Explanation

D. A weight loss of 1.8 kg (4 lb) in the past 24 hours indicates effective diuresis (urine output) and reduction in fluid volume, which is the therapeutic goal of furosemide in treating pulmonary edema.

A Furosemide is a loop diuretic that typically causes a decrease in blood pressure by promoting the excretion of excess fluid and sodium from the body.

B. Adventitious breath sounds such as crackles (rales) indicate the presence of fluid in the lungs, which is a characteristic finding in pulmonary edema.

C. A respiratory rate of 24 breaths per minute is within normal range for an adult at rest. While this respiratory rate is not abnormal, it also does not directly indicate whether furosemide is effective in treating pulmonary edema.

A. Teach the client a breathing exercise with a longer inhalation phase. B. Limit fluid intake to 1,000 mL per day. C. Encourage use of incentive spirometry for 5 min every 2 hr. D. Administer oxygen at 2 L/min.

Correct Answer is D

Explanation

A Breathing exercises can help improve lung function and oxygenation. However, the specific type of breathing exercise is crucial. Emphysema typically involves air trapping due to loss of elasticity in the lungs, so teaching a breathing exercise with a longer exhalation phase (to facilitate complete exhalation and prevent air trapping) would be more beneficial than emphasizing a longer inhalation phase.

B. Fluid restriction is not typically indicated for clients with emphysema. It is more relevant for conditions where fluid overload can exacerbate symptoms (like congestive heart failure). In emphysema, maintaining adequate hydration is important to keep secretions thin and more manageable for clearing.

C.Incentive spirometry is used to help promote deep breathing and prevent atelectasis (lung collapse) by encouraging the client to take slow, deep breaths. However, incentive spirometry is typically more useful for clients recovering from surgery or immobilized clients rather than for those with emphysema.

D. The use of oxygen therapy at 2 L/min is a standard intervention for clients with emphysema who have low oxygen levels, as it helps maintain proper oxygenation. It is crucial to manage oxygen levels carefully to prevent complications such as hypoxia or pulmonary hypertension while avoiding excessive oxygen, which may reduce the patient's drive to breathe.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

Correct Answer is D

Explanation

A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

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