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.

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Correct Answer is D

Explanation

A. Pink, frothy sputum is typically associated with left-sided heart failure and pulmonary edema. This occurs when fluid backs up into the lungs due to left-sided heart failure. Since the question pertains to right-sided heart failure, this statement is not consistent with that condition.

B. Feeling short of breath when lying flat is known as orthopnea and is more commonly associated with left-sided heart failure. It occurs due to fluid shifting into the lungs when supine, which aggravates pulmonary congestion. This statement is not consistent with right-sided heart failure.
C. Hearing fluid in the lungs typically indicates left-sided heart failure, where fluid backs up into the pulmonary circulation, causing pulmonary edema. This symptom is associated with left-sided heart failure rather than right-sided heart failure.
D. Swelling of the legs, also known as peripheral edema, is a hallmark of right-sided heart failure. This occurs because the right side of the heart is unable to effectively pump blood out to the lungs, leading to fluid accumulation in the systemic venous circulation and resulting in swelling in the lower extremities and sometimes the abdomen

A. The late-phase response occurs due to an influx of additional inflammatory cells B. The symptoms of the late-phase response tend to respond better to a rescue inhaler than the symptoms of the early-phase response C. The late-phase response occurs because the client did not use their rescue inhaler properly D. The late-phase response only occurs if the client continues to be exposed to their trigger after the initial attack

Correct Answer is A

Explanation

A. The late-phase response in asthma is characterized by a delayed and prolonged inflammatory reaction that can occur 4 to 6 hours after exposure to a trigger. It involves the recruitment of additional inflammatory cells, such as eosinophils and T cells, which contribute to ongoing airway inflammation, increased mucus production, and bronchoconstriction. This phase often leads to a return of symptoms or worsening of symptoms after the initial relief provided by a rescue inhaler.
B. The late-phase response does not typically respond as well to rescue inhalers (such as albuterol) as the early-phase response does. Rescue inhalers are primarily effective for the immediate, bronchospastic component of asthma (early-phase response).
C. The late-phase response occurs as part of the natural progression of asthma inflammation and is not necessarily related to improper use of a rescue inhaler. Even with proper use of a rescue inhaler, the late-phase response can still occur due to the underlying inflammatory processes.
D. The late-phase response can occur even if the trigger is no longer present. It is related to the ongoing inflammatory process rather than continued exposure to the trigger. Although continued exposure to triggers can exacerbate symptoms, the late-phase response can still occur independently of further exposure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

A female client with systemic lupus erythematosus (SLE) asks the nurse about pregnancy and lupus. Which information should the nurse include when educating the client?

A client with a cold sore on the lip has been diagnosed with herpes simplex virus. Which neurological disorder may the client be at risk for in the future?

A nurse in an eye clinic is obtaining a health history from a client who is being evaluated for suspected cataracts. The nurse understands that which of the following medications is associated with an increased risk of developing cataracts?

The nurse is providing care for a geriatric patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate?

A nurse is assessing a client who has chronic kidney disease and notes that the client has small crystals on his forehead. The nurse understands that this manifestation is a result of an excess of which substance in the body?

A client is seen in a primary care provider's office. The client has gradually developed a stooped posture, shuffling gait, and a lack of facial expressions. Which medication should the nurse anticipate will be prescribed to treat these symptoms?

A nurse in a clinic is reviewing the home medications of client who has a history of asthma, and who is at the clinic to have a routine annual physical. Which statement made by the patient would indicate a need for further action by the nurse?