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%
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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Related Questions
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.
Correct Answer is A
Explanation
A. Agitation can be a manifestation of hypoxia. As the body senses inadequate oxygen supply, it may respond with restlessness or agitation as a compensatory mechanism to increase oxygen intake.
B. Nausea is not a typical finding in hypoxia.
C. Dysphagia refers to difficulty swallowing and is not typically associated with hypoxia. It is more commonly related to neurological or structural issues affecting the swallowing mechanism.
D. Warm, dry skin is not a typical manifestation of hypoxia. In fact, hypoxia often results in cool, clammy, or cyanotic (bluish) skin due to inadequate oxygen perfusion.
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