A nurse on a Medical-Surgical unit is performing an assessment on a client who has COPD with emphysema. The client reports that he has a frequent wet cough and is occasionally short-of-breath. The nurse should anticipate which of the following assessment findings for this client?
Petechiae on the chest.
Increased anteroposterior diameter of the chest.
Oxygen saturation level 96%.
Respiratory alkalosis.
The Correct Answer is B
The correct answer is choice B. Increased anteroposterior diameter of the chest.
Choice A rationale:
Petechiae on the chest (Choice A) are tiny red or purple spots that appear on the skin due to small blood vessel breakage. They are not typically associated with COPD and emphysema. Petechiae are more often related to conditions like thrombocytopenia or certain infections, where blood clotting is impaired.
Choice B rationale:
Increased anteroposterior diameter of the chest, often referred to as "barrel chest," is a characteristic finding in clients with COPD and emphysema. This occurs due to the hyperinflation of the lungs and the loss of elasticity in the lung tissues, which causes the chest to become rounded and the ribs to be positioned more horizontally.
Choice C rationale:
An oxygen saturation level of 96% (Choice C) is within the normal range for oxygen saturation. However, while it's important for clients with COPD to maintain adequate oxygen levels, this value doesn't specifically correlate with the client's symptoms of a wet cough and occasional shortness of breath.
Choice D rationale:
Respiratory alkalosis (Choice D) involves an increase in blood pH due to decreased levels of carbon dioxide (hypocapnia) caused by hyperventilation. While respiratory alkalosis can occur in clients with COPD due to compensatory hyperventilation, it is not a direct assessment finding related to the client's symptoms of a wet cough and occasional shortness of breath.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Applying petroleum jelly to the nares is not necessary in this situation. Oxygen therapy through a nasal cannula aims to deliver oxygen to the client's respiratory system. Applying petroleum jelly might interfere with the oxygen delivery and is not a standard practice.
Choice B rationale:
Removing the nasal cannula while the client eats reduces the oxygen supply during a time when the body's oxygen demand might increase due to the digestive process. It's important to maintain consistent oxygen therapy, even during meals.
Choice C rationale:
Attaching a humidifier bottle to the base of the flow meter is not necessary for oxygen therapy at 5 L/min via nasal cannula. Humidification is usually needed at higher oxygen flow rates to prevent drying of the mucous membranes.
Choice D rationale:
Securing the oxygen tubing to the bed sheet near the client's head is the correct action. This ensures that the tubing is not pulled or tugged during movement, maintaining a steady flow of oxygen. Placing it near the client's head prevents kinking or tangling of the tubing and allows the client to move without disrupting the therapy.
Correct Answer is D
Explanation
Choice A rationale:
Love and belonging. Maslow's Hierarchy of Needs outlines a pyramid of human needs, starting from basic physiological needs at the bottom and progressing to higher-level psychological and self-fulfillment needs. Love and belonging are higher-level needs, and individuals typically address them after their basic physiological needs are met. Basic needs like food, water, and shelter take precedence over higher-level emotional needs. In this case, the client's most immediate need would be to satisfy their hunger and thirst.
Choice B rationale:
Psychological security. Psychological security is another higher-level need related to safety and a sense of protection. While it is important, it is not the most immediate need according to Maslow's Hierarchy of Needs. The client would prioritize fulfilling their basic physiological needs before seeking psychological security.
Choice C rationale:
Self-actualization. Self-actualization is the highest level of need in Maslow's Hierarchy, encompassing personal growth, fulfillment, and achieving one's potential. It is a need that individuals pursue once their lower-level needs are satisfied. Since the question pertains to the first need the client would seek to meet, self-actualization is not the correct answer.
Choice D rationale:
Food and water. Food and water are fundamental physiological needs that form the base of Maslow's Hierarchy. These needs must be met before an individual can move on to addressing higher-level needs. Without addressing the need for sustenance, the client's ability to seek love, belonging, security, or self-actualization would be compromised.
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