A nurse is receiving morning report when an alarm notifies the nurse that a client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 89%. The nurse immediately assesses the client, and finds the client resting comfortably in bed on 2 liters of supplemental oxygen via nasal cannula. The client denies distress. Which of the following is the most appropriate nursing action?

Continue to monitor the patient

Silence future alarms

Place the patient on a non-rebreather mask

Increase the oxygen to 4 liters per minute

Answer and Explanation

The Correct Answer is A

A.   The client is resting comfortably, denies distress, and has an oxygen saturation of 89% on 2 liters of supplemental oxygen. This is within an acceptable range for many patients with COPD. Given the client's current status, it is appropriate to continue monitoring the oxygen saturation and assess for any changes in condition.
B.   While the alarm may be annoying, it is important to keep it active to alert the nurse to any significant changes in the client's oxygen saturation.
C.   A non-rebreather mask delivers a higher concentration of oxygen and is typically used in more critical situations. In this case, the client's oxygen saturation is within a safe range, and there is no need to increase the oxygen delivery method.
D.   Increasing the oxygen to 4 liters per minute without a clear indication of need could lead to oxygen toxicity, especially in patients with COPD. It is important to titrate oxygen therapy to the lowest level that maintains adequate oxygen saturation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Hemoglobin levels measure the oxygen-carrying capacity of the blood. A reduced ejection fraction (30%) is more closely related to heart failure or significant cardiac dysfunction, which is not directly indicated by changes in hemoglobin levels.
B. Platelet levels are primarily involved in blood clotting and are less directly related to ejection fraction. Elevated or decreased platelet counts are not typically used as indicators of heart failure severity or reduced ejection fraction.
C. In cases of severe heart failure with a reduced ejection fraction, you may see elevated BUN levels due to these effects. However, it is not directly related to heart failure.
D. BNP is a hormone released by the heart in response to increased pressure and volume overload, typically seen in heart failure. Elevated BNP levels are associated with worsening heart failure and can be elevated in patients with a reduced ejection fraction. In heart failure, especially with an ejection fraction as low as 30%, BNP levels are often significantly elevated.

A. Low adrenocorticotropic hormone (ACTH) and low cortisol B. Elevated adrenocorticotropic hormone (ACTH) and elevated cortisol C. Low adrenocorticotropic hormone (ACTH) and elevated cortisol D. Elevated adrenocorticotropic hormone (ACTH) and low cortisol

Correct Answer is C

Explanation

A. This would indicate adrenal insufficiency, not Cushing syndrome.
B. Elevated adrenocorticotropic hormone (ACTH) and elevated cortisol would indicate Cushing syndrome caused by pituitary adenoma, not adrenal gland hyperplasia.
C. Low adrenocorticotropic hormone (ACTH) and elevated cortisol is consistent with Cushing syndrome caused by adrenal gland hyperplasia. In this condition, the adrenal glands produce excess cortisol independently of ACTH stimulation.
D. Elevated adrenocorticotropic hormone (ACTH) and low cortisol would indicate adrenal insufficiency, not Cushing syndrome.

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the results of the client's echocardiogram and observes that the ejection fraction is 30%. Which lab result would the nurse expect to be elevated for a client with this ejection fraction?

Correct Answer is D

Explanation

A nurse is caring for a client who has a diagnosis of Cushing syndrome. After performing magnetic resonance imaging (MRI), the underlying cause of the condition is found to be hyperplasia of the adrenal glands. Which of the following lab results would the nurse anticipate with this condition?

Correct Answer is C

Explanation

A nurse educator is providing an educational in-service about various neurological disorders. Which statement should be included when teaching about Guillain-Barre Syndrome?

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