A nurse is caring for a client who has COPD.
Medication
Indacaterol 75 mcg, one inhalation daily
Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake
Select the 5 findings that require follow-up.
Disorientation
Barrel-shaped chest
Yellow sputum
Nebulizer use
Ankle edema
SaO2 92%
Clubbing of fingers
Correct Answer : A,B,C,E,F
A. Disorientation:
This may indicate a neurological or cognitive issue and requires further assessment.
B. Barrel-shaped chest:
This is a characteristic finding in COPD, but any change or worsening may need evaluation.
C. Yellow sputum:
Yellow or greenish sputum may indicate an infection, and follow-up is needed.
D. Nebulizer use:
Nebulizer use is part of the prescribed treatment.
E. Ankle edema:
Edema can be a sign of heart failure or other cardiovascular issues and should be investigated.
F. SaO2 92%:
Oxygen saturation of 92% is below the normal range. It may indicate respiratory compromise and needs attention.
G. Clubbing of fingers:
While clubbing can be associated with chronic respiratory conditions, it is not an immediate concern.
H. Lives alone:
Living alone may impact the client's support system but does not require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Aplastic anemia results in an inability to absorb vitamin B12: This statement is incorrect. Aplastic anemia is not related to the absorption of vitamin B12. It primarily involves a decrease in the production of blood cells by the bone marrow.
B. Aplastic anemia results from decreased bone marrow production of RBCs: This is the correct information. Aplastic anemia is a condition characterized by the failure of the bone marrow to produce an adequate number of blood cells, including red blood cells (RBCs), white blood cells (WBCs), and platelets.
C. Aplastic anemia results in an increased rate of RBC destruction: This statement is incorrect. Aplastic anemia is not associated with an increased rate of RBC destruction. Instead, it is characterized by a reduction in the number of blood cells produced by the bone marrow.
D. Aplastic anemia is associated with a decreased intake of iron: This statement is incorrect. Aplastic anemia is not related to a decreased intake of iron. It is primarily a disorder of bone marrow function leading to insufficient production of blood cells.
Correct Answer is C
Explanation
A. Bradypnea: Bradypnea refers to abnormally slow breathing. In the context of postoperative atelectasis and hypoxia, the client is more likely to exhibit tachypnea (rapid breathing) as the body attempts to compensate for reduced oxygen levels.
B. Bradycardia: Bradycardia is an abnormally slow heart rate. While hypoxia can lead to changes in heart rate, it is more common to observe tachycardia (increased heart rate) as a compensatory response to decreased oxygen levels.
C. Intercostal retractions: Intercostal retractions occur when the muscles between the ribs pull inward during inspiration. In a client with atelectasis and hypoxia, increased respiratory effort may result in intercostal retractions as the body tries to enhance airflow and improve oxygenation.
D. Lethargy: Lethargy refers to a state of drowsiness or fatigue. While hypoxia can lead to lethargy, it is not a specific respiratory manifestation. Other respiratory signs, such as increased respiratory rate and retractions, are more likely to be observed.
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