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 D

Explanation

This is because burns to the face, neck, and upper extremities can compromise the airway, circulation, and mobility of the client. The nurse should monitor for signs of respiratory distress, infection, and contractures in these areas.

A. WBC 5,000/mm3 B. Platelets 150,000/mm3 C. Positive Western blot test D. CD4-T-cell count 180 cells/mm3

Correct Answer is D

Explanation

CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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