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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Malnutrition itself is not a direct cause of healthcare-associated infections (HAIs).
B. While having multiple caregivers can potentially increase the risk of transmission of infections if proper hand hygiene and infection control practices are not followed, it is not a direct cause of HAIs. Proper adherence to infection control protocols mitigates this risk.
C. Urinary catheterization is a common cause of healthcare-associated infections, particularly urinary tract infections (UTIs). Catheters provide a pathway for bacteria to enter the urinary tract, leading to infection if not managed properly or if left in place longer than necessary.
D. Chlorhexidine washes are actually used as an infection prevention measure rather than a cause of HAIs. Chlorhexidine is an antiseptic agent that is effective against a wide range of microorganisms and is used for preoperative skin cleansing, central line care, and other procedures to reduce the risk of infections.

A. Allow the client to expel some fluid before continuing. B. Lower the height of the solution container. C. Encourage the client to bear down. D. Stop the enema and document that the client did not tolerate the procedure.

Correct Answer is B

Explanation

A. Expulsion of water does not address the underlying issue.
B. Lowering the height of the solution container can help reduce the force of the fluid entering the colon, which may lessen cramping. This method slows the flow rate of the solution, allowing the client's body to adjust without stopping the procedure entirely.
C. Bearing down (straining) may increase the discomfort and is not recommended during the administration of an enema. It could potentially lead to rectal trauma or increase intrarectal pressure, which is not beneficial during the procedure.

D. While stopping the procedure is an option if the client is unable to tolerate it due to severe discomfort or distress, in this scenario where cramping is the main issue, allowing the client to expel some fluid is more appropriate before deciding to stop the procedure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Correct Answer is C

Explanation

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L. sodium 138 mEq/L and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?

The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?