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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 C

Explanation

A. The pain persists with rest and organic nitrates: This statement is incorrect. Anginal pain typically improves with rest and can be relieved by the administration of organic nitrates.

B. The pain usually lasts longer than 20 min: This statement is incorrect. Anginal pain is often brief and lasts for a few minutes, typically less than 20 minutes.

C. Exertion and anxiety can trigger the pain: This is the correct answer. Anginal pain is often triggered by activities that increase the workload of the heart, such as exertion or emotional stress (anxiety). These triggers lead to an increased demand for oxygen by the heart muscle, which may exceed the compromised blood supply, resulting in angina.

D. The pain often radiates to the jaw or the back: This statement is correct. Anginal pain may radiate to the jaw, back, shoulder, arm, or neck. The radiation of pain is a characteristic feature of angina.

A. Instruct the woman to call 911. B. Use the abdominal-thrust maneuver. C. Ask the partner if he can speak. D. Perform chest compressions.

Correct Answer is B

Explanation

A. Instruct the woman to call 911: This is a correct action, but it should be the second step after the nurse initiates first aid measures. Directing someone to call for emergency assistance is crucial, but immediate intervention to relieve the choking takes precedence.

B. The Heimlich maneuver involves abdominal thrusts and is the recommended technique for relieving choking in a conscious person. It is essential to act quickly and decisively to clear the airway.

C. Ask the partner if he can speak: If the person is unable to speak, cough, or breathe, it may indicate complete airway obstruction. The nurse should not delay intervention by asking if the person can speak but should immediately proceed with measures to relieve the choking.

D. Perform chest compressions: Chest compressions are not indicated for a conscious choking victim. Chest compressions are performed in the context of cardiopulmonary resuscitation (CPR) for an unconscious person with no pulse.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

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.