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 A
Explanation
A This statement indicates an understanding of the right to refuse treatment at any time, even after it has been initiated. Clients have the right to change their mind about treatment options and can withdraw their consent at any stage of treatment.
B. This statement suggests a misunderstanding of informed consent. Informed consent means the client understands the risks, benefits, and alternatives to a proposed treatment or procedure. Signing a consent form because one believes there are no other options does not reflect an informed decision- making process.
C. This statement indicates a misconception about treatment options. Clients have the right to refuse a specific treatment plan or procedure and explore other options or seek a second opinion. Refusal of one treatment does not necessarily preclude the possibility of pursuing alternative treatments.
D. This statement indicates a misunderstanding of the risks associated with treatment. It's crucial for clients to understand both the potential benefits and possible adverse effects of any treatment they undergo. Radiation treatment, like any medical intervention, carries risks that should be weighed against potential benefits.
Correct Answer is D
Explanation
D. Paraplegia significantly increases the risk of skin breakdown due to immobility, lack of sensation, and prolonged pressure on specific areas of the body. These clients require meticulous skin care and frequent repositioning to prevent pressure injuries.
A While urinary incontinence can contribute to skin breakdown, especially if not managed properly, it may not pose as great a risk compared to other factors like poor nutrition or immobility.
B. Poor nutrition compromises skin integrity by reducing the skin's ability to repair and maintain itself, making it more susceptible to breakdown. This factor significantly increases the risk of developing pressure ulcers and other skin lesions.
C. Clients with Alzheimer's disease may have increased risk due to various factors such as mobility issues, impaired sensation, and difficulty with self-care. However, the degree of risk can vary depending on the stage of the disease and individual circumstances.
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