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. The oral mucosa, especially the lips and tongue, is a reliable indicator of central cyanosis. Cyanosis is evident as bluish discoloration in these areas due to the presence of deoxygenated hemoglobin.
B. Cyanosis is less reliably visible on the eyelids compared to the lips and oral mucosa. Skin over the eyelids is typically thinner, but detection of cyanosis here can be more challenging due to variations in skin pigmentation and thickness.
C. Similar to the eyelids, cyanosis may be less evident on the ear lobes compared to the lips and oral mucosa. Ear lobes are less vascular and may not consistently show cyanosis unless the condition is severe.
D. The tip of the nose is another area where cyanosis can be detected, although it is less reliable than the lips and oral mucosa. Like the eyelids and ear lobes, the detection of cyanosis here can vary depending on individual skin characteristics.

A. "Keep your eye open for 30 sec after instilling the ointment." B. "Apply the ointment in a thin line into the conjunctival sac." C. "Always wipe from the outer to the inner canthus when wiping away secretions." D. "Use a sterile glove and applicator to apply the antibiotic ointment."

Correct Answer is B

Explanation

A. This statement is incorrect because after instilling ointment, the client should close their eye gently and avoid blinking to allow the ointment to spread over the conjunctival sac.
B. When applying ophthalmic ointment, the client should pull down the lower eyelid to create a small pocket (conjunctival sac) and then apply a thin line of ointment along this pocket. This method helps the ointment distribute evenly over the affected area.
C. While this is a correct technique for cleaning around the eye, it is not directly related to the application of ophthalmic ointment.
D. This statement is unnecessary and may confuse the client. It's typically not required to use sterile gloves for applying ophthalmic ointment, and most ointments come with a sterile applicator or can be applied using clean hands if instructed to do so by a healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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