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 A
Explanation
A. Hacking cough: This is the correct answer. Left-sided heart failure can lead to pulmonary congestion, resulting in a cough that is often described as "hacking" or "persistent." This cough may be worse at night when the client is lying down.
B. Abdominal distension: Abdominal distension is more commonly associated with right-sided heart failure, as fluid accumulates in the abdomen (ascites). In left-sided heart failure, fluid accumulates in the lungs, leading to pulmonary symptoms.
C. Dependent edema: Dependent edema is also more commonly associated with right-sided heart failure. In left-sided heart failure, fluid tends to accumulate in the lungs, causing pulmonary congestion and related symptoms.
D. Jugular venous distention: Jugular venous distention is often seen in right-sided heart failure due to impaired blood flow from the right atrium into the right ventricle. This finding is less likely to be prominent in left-sided heart failure.
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