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. This option is aimed at modifying the consistency of fluids to make them easier to swallow for someone with dysphagia. Thickened liquids are often recommended to prevent aspiration (when food or liquid enters the airway instead of the esophagus) in patients with swallowing difficulties.
B. Placing food on the unaffected side of the mouth, which would be the right side in the case of left-sided weakness, is recommended to aid in easier chewing and swallowing.
C. Temperature can affect how easily food can be swallowed and enjoyed by someone with dysphagia. Extremely hot or cold foods can be more challenging to swallow. However, this dose not address the risk of aspiration.
D. Tipping the head back during swallowing is not recommended because it can increase the risk of choking or aspiration. Instead of tilting the head back, clients with dysphagia should be instructed to maintain an upright position when eating and drinking.

A. Avoid applying pressure to the tragus of the ear. B. Don sterile gloves to instill the medication C. Pull the pinna upward and backward. D. Chill the otic solution prior to administration.

Correct Answer is C

Explanation

A. The tragus is a small projection of cartilage in front of the ear canal. Applying gentle pressure to the tragus after instilling ear drops helps to facilitate the passage of the drops into the ear canal. This action should not be avoided; rather, it is recommended to enhance the delivery of the medication.
B. Sterile gloves are not typically necessary for instilling ear drops unless the client has an open or infected ear canal. Using clean, non-sterile gloves or practicing proper hand hygiene is sufficient to maintain cleanliness during the procedure.
C. For an adult client, pulling the pinna (outer ear) upward and backward helps to straighten the ear canal. This allows the drops to flow easily into the ear canal rather than pooling in the outer ear or leaking out. This technique ensures that the medication reaches the target area effectively.
D. Chilling otic (ear) solutions is not recommended unless specifically instructed by the healthcare provider for therapeutic reasons (e.g., to soothe ear pain or inflammation). Cold solutions can cause discomfort or dizziness when instilled into the ear. Therefore, otic solutions are typically administered at room temperature to avoid these adverse effects.

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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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