Try Naxlex NCLEX-RN (Free-Trial)

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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

a. Oil-based lubricant

Explanation:

The correct answer is a. Oil-based lubricant.

When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.

Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a diﬀerent procedure and indication

Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.

Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body ﬂuids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.

By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.

A. A client who has a new onset of chest pain B. A client who has a tracheostomy C. A client who is receiving enteral feedings D. A client who has urinary retention

Correct Answer is A

Explanation

The nurse should identify that caring for a client who has a new onset of chest pain is outside the scope of practice for an LPN. This is a complex and potentially life-threatening situation that requires the assessment and intervention of a registered nurse (RN) or other advanced practice provider.

b) Caring for a client who has a tracheostomy is within the scope of practice for an LPN.

c) Caring for a client who is receiving enteral feedings is within the scope of practice for an LPN.

d) Caring for a client who has urinary retention is within the scope of practice for an LPN.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure?

Correct Answer is D

Explanation

A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN?

Correct Answer is A

Explanation

A nurse is caring for several clients who are receiving well-child check-ups. The nurse should identify that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for which of the following clients?

A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain, swelling, and stiﬀness. Which of the following client statements indicates understanding of the teaching?

A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of the following techniques should the nurse plan to use to assist with time management?

A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?

A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?

A nurse in a long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first?

A nurse is caring for a client who was recently admited to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?

A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?