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","C","D","E"]
Explanation
Asthma action plans often use a color-coded system to guide management based on peak expiratory flow rate (PEFR) measurements. The zones are typically green (80-100% of personal best), yellow (50-79% of personal best), and red (less than 50% of personal best).
A. The student needs to go to the hospital.
This is not necessarily required when the student is in the yellow zone. The yellow zone indicates caution and the need for intervention, but it does not immediately require hospitalization unless symptoms worsen or do not improve after using the quick-relief inhaler.
B. The nurse should obtain a second expiratory flow rate.
Confirming the peak flow measurement with a second reading ensures accuracy and helps to make informed decisions about the student's asthma management.
C. The student should use his quick-relief inhaler.
In the yellow zone, indicating moderate impairment, the use of a quick-relief (rescue) inhaler is often recommended to relieve symptoms and prevent progression to the red zone.
D. The student's peak flow is 50% to 80% of his best peak flow.
This is the correct range for the yellow zone, indicating moderate impairment. Action is needed to prevent worsening.
E. The student's asthma is not well controlled.
Being in the yellow zone indicates that the asthma is not well controlled and may require adjustments in the long-term management plan, including possible changes to daily controller medications.
Correct Answer is D
Explanation
A. Restrict the client's fluid intake: There is typically no need to restrict fluid intake after a cardiac catheterization. Adequate hydration is important for preventing complications and promoting recovery.
B. Ambulate the client 1 hr following the procedure: While early ambulation is encouraged in many cases, the timing may vary based on the specific protocols of the healthcare provider. It is important to follow the healthcare provider's orders regarding post-catheterization ambulation.
C. Instruct the client to perform range-of-motion exercises to his lower extremities: Range-of-motion exercises are beneficial to prevent complications such as venous stasis and deep vein thrombosis. However, the specific exercises and timing may vary. It is important to follow the healthcare provider's instructions.
D. Perform neurovascular checks with vital signs: This is the correct answer. After a cardiac catheterization accessed through the femoral artery, it is crucial to monitor neurovascular status in the affected extremity. Assessing peripheral pulses, skin color, temperature, and capillary refill, along with monitoring vital signs, helps detect any signs of complications such as bleeding or vascular compromise.
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