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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Malignant melanoma is a rare but aggressive type of skin cancer that originates from melanocytes, the cells that produce pigment in the skin. It can appear as a new or changing mole that has an irregular shape, uneven color, large size, or bleeding tendency. It may also be purplish in color due to vascular invasion or hemorrhage within the lesion.

A. Difficulty swallowing B. Urinary output 25 mL/hr C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10

Correct Answer is A

Explanation

Difficulty swallowing is the priority finding to report to the provider. Rationale: This is because difficulty swallowing can indicate airway edema, which can compromise breathing and oxygenation. The nurse should monitor the client's respiratory status and administer oxygen as prescribed. The other findings are also important, but not as urgent as airway obstruction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion?

Correct Answer is C

Explanation

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme- linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?

Exhibits A nurse in a community health clinic is caring for a client who has a history of HIV. For each of the following assessment findings for the client, identify if the finding is consistent with HIV stage I or HIV stage III (AIDS). Each finding may support more than one disease process.