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. Administering tube feedings while the client is in a supine (flat on their back) position can increase the risk of aspiration. Ideally, clients should be positioned upright or at a 30-45 degree angle during and after tube feedings to reduce the risk of reflux and aspiration.
B. Flushing the NG tube with tap water after feeding is just a standard practice to prevent clogging and maintain tube patency.

C. Administering tube feedings by gravity using a syringe barrel is an appropriate method. This allows for controlled and slow administration of the feeding solution, minimizing the risk of overfeeding or complications.
D. Aspirating gastric residual before initiating tube feedings is a standard practice to assess the amount of residual contents in the stomach. However, the amount of residual aspirate that warrants intervention can vary based on institutional policies and the client's condition.

A. Notify the provider. B. Determine the patency of the tubing. C. Offer oral fluids. D. Administer a prescribed analgesic.

Correct Answer is B

Explanation

A. This option involves informing the healthcare provider about the lack of urinary output. This is important because it could indicate an obstruction or clot formation in the urinary catheter or drainage system, which may require immediate intervention.
B. Checking the patency of the urinary catheter tubing is crucial. The nurse should assess for any kinks, twists, or clots that may be obstructing urine flow. Flushing the catheter per protocol or irrigating it with sterile saline may help clear any obstruction.
C. Increasing oral fluids may help promote urine production once any obstruction or issue with the catheter is resolved. However, this action should come after addressing the immediate concern of no urinary output and ensuring the catheter's patency.
D. While pain management is important postoperatively, administering an analgesic is not the priority in this scenario where there is no urinary output. Pain from the procedure is typically managed with medications prescribed on a schedule or as needed, but it does not address the acute issue of urinary obstruction.

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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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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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