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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Volunteer to provide an inservice about infection control.While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol.Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP.This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training.Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

A. Provide wound irrigation. B. Avoid accidentally removing the drain. C. Gather supplies. D. Provide analgesic medication as ordered by Provider.

Correct Answer is C

Explanation

Choice A rationale:

Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.

Choice B rationale:

While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.

Choice C rationale:

Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.

Choice D rationale:

Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

Correct Answer is C

Explanation

A Medical-Surgical nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

A nurse is reviewing unintentional and intentional torts. Which of the following clinical situations would the nurse identify as an example of assault?

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

A Medical-Surgical nurse is preparing to administer Furosemide to a patient who is having severe heart failure. Which route of administration should the nurse use to provide the fastest and most complete absorption of Furosemide?

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?