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 D
Explanation
A. Serum amylase: Serum amylase is an enzyme associated with pancreatic function, and its elevation is not specific to myocardial infarction.
B. Unconjugated bilirubin: Elevation of unconjugated bilirubin is associated with liver function and hemolysis, not specifically with myocardial infarction.
C. Aspartate aminotransferase (AST): While AST may be elevated in conditions affecting the heart, it is not as specific or sensitive for myocardial infarction as troponin I.
D. Troponin I: This is the correct answer. Troponin I is a cardiac-specific biomarker released into the bloodstream when there is damage to cardiac muscle, such as during a myocardial infarction. Troponin I levels start to rise within 3-4 hours after the onset of myocardial infarction, making it a crucial marker for early detection.
Correct Answer is B
Explanation
A. "DIC is controllable with lifelong heparin usage": This statement is not accurate. While heparin may be used in the treatment of DIC, it is not a lifelong therapy, and the approach to treatment depends on the underlying cause.
B. "DIC is caused by abnormal coagulation involving fibrinogen": This is the correct answer. DIC is a condition characterized by widespread activation of the clotting cascade, leading to the formation of microthrombi throughout the body. Abnormal coagulation involves the consumption of clotting factors, including fibrinogen.
C. "DIC is a genetic disorder involving a vitamin K deficiency": This statement is not accurate. DIC is not a genetic disorder, and it is not primarily related to vitamin K deficiency. It is an acquired condition often associated with severe infections, sepsis, trauma, or other critical illnesses.
D. "DIC is characterized by an elevated platelet count": This statement is not accurate. In DIC, there is often a decrease in platelet count due to consumption and activation of platelets in the widespread formation of microthrombi.
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