A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?

Speaks in short phrases

Increased sputum production

Use of accessory muscles to breathe

Pulse oximetry reading of 90%

Answer and Explanation

The Correct Answer is C

A.   Speaking in short phrases can indicate increased effort or difficulty in breathing. While it suggests respiratory compromise, it is not an immediate concern unless it worsens or is accompanied by other severe symptoms.
B.   Increased sputum production is common in clients with COPD and can indicate exacerbation or infection. It should be monitored closely but may not require immediate reporting unless it is severe or associated with other concerning symptoms.
C.   This finding indicates increased respiratory effort and potential respiratory distress, which requires prompt attention and intervention.
D.   A pulse oximetry reading of 90% indicates that the client's oxygen saturation is below the normal range but acceptable in client with COPD due to chronic hypoxemia.

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Correct Answer is A

Explanation

A. Atrial fibrillation is characterized by an irregularly irregular pulse. This means that the rhythm of the pulse lacks a discernible pattern; it may be irregularly fast or slow, with varying intervals between beats. Therefore, "irregular" is an appropriate term to describe the quality of the pulse in a client with atrial fibrillation.
B. While some clients with atrial fibrillation may have a slow heart rate (bradycardia), not all do. Atrial fibrillation itself typically presents with an irregular rhythm rather than a consistently slow pulse rate. Thus, "slow" may not accurately describe the quality of the pulse in atrial fibrillation.
C. "Not palpable" refers to the inability to feel or detect a pulse. In atrial fibrillation, the pulse is usually palpable but irregular. Therefore, "not palpable" would not be an accurate term to describe the pulse quality in this condition.
D. "Bounding" describes a pulse that is strong and forceful. In atrial fibrillation, the pulse may vary in strength and typically does not have a bounding quality. This term would not accurately describe the pulse quality in a client with atrial fibrillation.

A. Stiffness in the lower extremities B. A reddened area over the sacrum C. Difficulty hearing some types of sounds D. Difficulty moving the upper extremities

Correct Answer is B

Explanation

A. Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B. A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C. Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D. Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.

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A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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