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 B
Explanation
b. A decreased level of consciousness and vomiting
Explanation:
When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.
Explanation for the other options:
a. Cellulitis accompanied by a low-grade fever:
While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.
c. A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago:
Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.
d. Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL:
While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.
In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.
Correct Answer is D
Explanation
Neisseria gonorrhoeae is the bacterium responsible for the sexually transmitted infection known as gonorrhea. Gonorrhea is a reportable communicable disease, meaning healthcare providers are required to report cases to the appropriate public health authorities. This allows for tracking and monitoring of the disease, implementation of appropriate public health measures, and prevention of further spread of the infection.
Sarcoptes scabiei: This refers to scabies, a parasitic infestation caused by mites. While scabies can be contagious, it is not typically a reportable disease to the state health department.
Impetigo contagiosa: Impetigo is a bacterial skin infection that can be caused by various bacteria, including Staphylococcus aureus and Streptococcus pyogenes. Although it is contagious, it is not typically a reportable disease to the state health department.
Human papillomavirus (HPV): HPV is a viral infection transmitted through sexual contact. While it is a significant public health concern due to its association with cervical cancer and other conditions, it is not usually a reportable disease to the state health department. However, certain states may have specific reporting requirements for HPV-related diseases or conditions, such as cervical cancer. It is important to be familiar with the specific reporting guidelines of the state in question.
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