A nurse is caring for a client who has COPD. The nurse should identify that which of the following findings is the priority to report?
Hgb 20 g/dL
Oxygen saturation 92%
Productive cough with green sputum
Chest x-ray shows hyperinflation of lungs
The Correct Answer is A
Answer: A
Rationale:
A) Hgb 20 g/dL:
A hemoglobin level of 20 g/dL is elevated and suggests polycythemia, which can occur in chronic respiratory conditions like COPD due to chronic hypoxia. Elevated hemoglobin levels can increase blood viscosity, leading to complications such as increased risk of thrombosis and cardiovascular stress. This finding indicates a potentially serious issue and should be reported to the healthcare provider immediately to address any underlying causes and manage the client's condition effectively.
B) Oxygen saturation 92%:
An oxygen saturation of 92% is slightly below the typical normal range (95-100%) but is not immediately life-threatening. While it indicates mild hypoxemia, it is a common finding in COPD patients, and the management would typically involve supplemental oxygen or adjustment of therapy. This finding should be monitored but is not the most critical issue to report immediately.
C) Productive cough with green sputum:
A productive cough with green sputum suggests a possible infection or exacerbation of COPD. Although this is an important finding that requires evaluation and possible treatment, it is less critical than an elevated hemoglobin level, which indicates a more acute systemic issue. The green sputum should be reported and managed, but it is not the priority compared to the elevated hemoglobin.
D) Chest x-ray shows hyperinflation of lungs:
Hyperinflation of the lungs is a common radiological finding in COPD due to air trapping. While it is a significant finding, it is generally consistent with the disease's progression and does not indicate an acute problem requiring immediate intervention. Monitoring and managing the underlying COPD are necessary, but this finding is less urgent than the elevated hemoglobin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Montelukast is a medication commonly prescribed for the management of asthma symptoms, including the prevention of asthma attacks. The recommended dosing regimen for montelukast is typically once daily, usually in the evening. This helps to provide continuous control of asthma symptoms and reduce the risk of asthma exacerbations.
Administer the medication when the toddler has an acute asthma attack: Montelukast is not intended for immediate relief during an acute asthma attack. It is a long-term control medication aimed at preventing asthma symptoms and reducing the frequency and severity of attacks. For acute asthma attacks, a short-acting bronchodilator such as albuterol is typically used.
Provide an additional dose of the medication prior to physical activity: Montelukast is not specifically indicated as a pre-exercise medication for asthma. However, in some cases, healthcare providers may prescribe it if exercise-induced bronchoconstriction is a significant concern. It is important to follow the specific instructions provided by the healthcare provider regarding medication use before physical activity.
Mix the medication in juice prior to administration: Montelukast tablets or chewable tablets should not be crushed or mixed in juice unless specifically instructed by the healthcare provider. They should be administered whole and taken with water. If the child has difficulty swallowing tablets, alternative formulations like oral granules or chewable tablets may be available.
Correct Answer is D
Explanation
When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.
The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.
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