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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Platelets 156,000/mm³: This platelet count is within the normal range (normal range: 150,000 to 400,000/mm³). Although disseminated intravascular coagulopathy (DIC) can lead to thrombocytopenia (low platelet count), the platelet count in this scenario is not indicative of DIC.

B. Fibrinogen 85 mg/dL: This is the correct answer. A decreased fibrinogen level is often seen in DIC. Fibrinogen is consumed in the formation of microclots, and a low level may indicate ongoing coagulation.

C. PT 12 seconds: The prothrombin time (PT) is within the normal range. In DIC, the PT may be prolonged due to the consumption of clotting factors, but in this case, the PT is normal.

D. PTT 64 seconds: The partial thromboplastin time (PTT) is prolonged, which can be an indication of DIC. However, the more specific indicator in this scenario is the low fibrinogen level.

A. Aortic regurgitation, B. Mitral stenosis C. Aortic stenosis D. Mitral valve prolapse

Correct Answer is D

Explanation

A. Aortic regurgitation: Aortic regurgitation typically presents with a diastolic murmur, not a systolic click.

B. Mitral stenosis: Mitral stenosis presents with a diastolic murmur, often associated with an opening snap, rather than a systolic click.

C. Aortic stenosis: Aortic stenosis typically presents with a systolic ejection murmur, but not a systolic click.

D. Mitral valve prolapse: This is the correct answer. Mitral valve prolapse (MVP) is characterized by the displacement of the mitral valve leaflets into the left atrium during systole, often producing a systolic click. Symptoms associated with MVP can include atypical chest pain, palpitations, and exercise intolerance.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse in a provider's office is assessing a client who reports occasional atypical chest pain, palpitations, and exercise intolerance. On auscultation, the nurse notes a systolic click. The nurse should recognize this finding as a manifestation of which of the following conditions?

Correct Answer is D

Explanation

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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.