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 ["A","C","D"]

Explanation

These interventions can help prevent complications such as stress ulcers, ventilator-associated pneumonia, and aspiration. Pantoprazole reduces gastric acid secretion and protects the mucosa from erosion. Verifying the ventilator settings ensures that the client is receiving adequate oxygenation and ventilation according to their needs and goals. Elevating the head of the bed reduces the risk of aspiration and improves lung expansion.

A. Soles of the feet B. Ear lobes C. Oral mucosa D. Conjunctivae

Correct Answer is C

Explanation

This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.

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Naxlex Comprehensive Predictor Exams

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.)

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

Explanation

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Correct Answer is C

Explanation

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