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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.

A.

Disorientation

B.

Barrel-shaped chest

C.

Yellow sputum

D.

Nebulizer use

E.

Ankle edema

F.

SaO2 92%

G.

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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Related Questions

Correct Answer is C

Explanation

pH 7.22: Indicates acidosis (normal range: 7.35-7.45).

PaCO2 68 mm Hg: Elevated partial pressure of carbon dioxide, suggesting respiratory acidosis (normal range: 35-45 mm Hg).

Base excess -2: Indicates a mild metabolic acidosis.

PaO2 78 mm Hg: Within the normal range (80-100 mm Hg), indicating adequate oxygenation.

Saturation 80%: Below the normal range (95-100%), suggesting some degree of hypoxemia.

Bicarbonate 26 mEq/L: Elevated bicarbonate levels, suggesting metabolic compensation for the respiratory acidosis.

Therefore, the client is experiencing respiratory acidosis with partial metabolic compensation (mild metabolic acidosis).

Correct Answer is A

Explanation

A. "These tests help determine the degree of damage to the heart tissues." - This is the correct statement. Cardiac enzyme studies, such as creatine kinase (CK), CK-MB, troponin I, and troponin T, are used to assess the extent of myocardial damage during an acute myocardial infarction (MI). Elevated levels of these enzymes indicate myocardial injury and help healthcare providers determine the severity of the heart tissue damage.

B. "Cardiac enzymes will identify the location of the MI." - While cardiac enzymes can confirm the presence of an MI, they do not specifically identify the location of the infarction. Other diagnostic tools, such as electrocardiogram (ECG) and imaging studies, may help determine the location of the MI.

C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." - Cardiac enzymes are not used to diagnose pulmonary congestion. Other diagnostic methods, such as chest X-rays and physical examination, are more appropriate for assessing pulmonary congestion.

D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." - Cardiac enzyme studies do not provide information about the overall heart structure or the mobility of heart valves. Imaging studies, such as echocardiography, are used for this purpose.

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