A nurse is caring for a client who has COPD.

Nurses' Notes

Vital Signs

Medication

Home health nurse admission note:

Client discharged from healthcare facility yesterday following a 4-day stay for exacerbation of COPD. Lives alone; alert and oriented to person, place, and time. Lung fields with scattered rhonchi throughout, cough productive for thick white sputum, dyspnea with minimal exertion.

Clubbing is noted on fingers, chest is barrel-shaped. Supplemental oxygen at 2L/min via nasal cannula.

Home Health Nurse Note 3 days following discharge from health care facility: Client sleeping in recliner with nasal canula on their lap; awakens easily and is oriented to person but disoriented to place and time.

Lung sounds with scattered rhonchi, cough productive for thick, yellow secretions. 2+pitting edema bilateral in ankles and feet.

Re-oriented client. Client states "I don't remember if I did that breathing machine thing you told me about."

Instructed client on oxygen use, safety, and nebulizer treatments. Elevated lower extremities.

Select the 5 findings that require follow-up.

Disorientation

Barrel-shaped chest

Yellow sputum

Nebulizer use

Ankle edema SaO2 92% Clubbing of fingers

Lives alone

Answer and Explanation

Correct Answer : A,C,D,E,F

- Disorientation may indicate hypoxia, infection, or medication side effects. - Yellow sputum may indicate a bacterial infection that requires antibiotics. - Nebulizer use may indicate that the client is not using it correctly or regularly as prescribed, which can affect their lung function and oxygenation. - Ankle edema may indicate fluid overload or heart failure, which can worsen COPD symptoms and increase the risk of complications.

- Living alone may pose safety risks for the client, especially if they are disoriented or have difficulty managing their oxygen and nebulizer treatments. The nurse should assess the client's support system and refer them to community resources if needed.

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Correct Answer is C

Explanation

The correct answer is choiceC. “I will follow a daily diet high in calories and protein.”

Choice A rationale:

Inhaling slowly through pursed lips is incorrect.The correct technique is toexhaleslowly through pursed lips, which helps to keep the airways open longer, allowing for better air exchange and reducing shortness of breath.

Choice B rationale:

Lying on the stomach to practice abdominal breathing is not a recommended strategy for managing emphysema.Abdominal or diaphragmatic breathing can be beneficial, but it is typically practiced in a comfortable, upright position.

Choice C rationale:

Clients with emphysema often have an increased caloric demand due to the effort required to breathe. A diet high in calories and protein can help maintain energy levels and prevent muscle wasting.

Choice D rationale:

Avoiding a flu shot is incorrect.Patients with emphysema are at higher risk for respiratory infections, and getting an annual flu shot is crucial to prevent complications.

A. The client has an increased risk of infection. B. The client should receive a diet with increased protein. C. The client has an increased risk for bleeding. D. The client should receive an erythropoiesis stimulating agent.

Correct Answer is ["A","C"]

Explanation

Answer: A. The client has an increased risk of infection.

Rationale: This is because the client's white blood cell (WBC) count is low, which indicates a compromised immune system. The normal range for WBC is 4,000 to 11,000/mm3. A low WBC count can be caused by chemotherapy, which is a common treatment for ovarian cancer. The nurse should monitor the client for signs of infection, such as fever, chills, redness, swelling, or drainage, and implement infection prevention measures, such as hand hygiene, sterile technique, and isolation precautions.

Answer: C. The client has an increased risk for bleeding.

Rationale: This is because the client's platelet count is low, which indicates a reduced ability to form clots and stop bleeding. The normal range for platelets is 150,000 to 400,000/mm3. A low platelet count can be caused by chemotherapy, which can damage the bone marrow where platelets are produced. The nurse should monitor the client for signs of bleeding, such as petechiae, ecchymosis, hematuria, or melena, and implement bleeding prevention measures, such as avoiding invasive procedures, applying pressure to puncture sites, and using soft-bristled toothbrushes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

Correct Answer is ["A","C"]

Explanation

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