A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?

Pulse oximetry reading of 95%

Decreased depth of respirations

Flaring of the nostrils

Respiratory rate of 16/min

Answer and Explanation

The Correct Answer is C

A. Pulse oximetry reading of 95%. COPD clients often have lower baseline oxygen levels (88-92%), making this reading unexpectedly high.

B. Decreased depth of respirations. COPD typically causes shallow and rapid breathing due to air trapping.

C. Flaring of the nostrils: Nostril flaring is a sign of increased respiratory effort, which is common in COPD exacerbations.

D. Respiratory rate of 16/min. → Normal range (12-20/min), not an expected finding during dyspnea.

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.

B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.

C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.

D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.

E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.

A. Provide the client with a referral to a support group. B. Encourage the client to view the body of their partner. C. Reinforce the need for the client to build new relationships. D. Encourage the client to share their thoughts and feelings.

Correct Answer is D

Explanation

A. Provide the client with a referral to a support group. Not the first priority; occurs later in the grieving process.

B. Encourage the client to view the body of their partner. Only appropriate if the client wants to do so.

C. Reinforce the need for the client to build new relationships. Insensitive and premature during initial grief.

D. Encourage the client to share their thoughts and feelings. Therapeutic communication is the first step in grief support, allowing the client to process emotions.

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A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","E"]

Explanation

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Correct Answer is D

Explanation

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