A nurse suspects impending respiratory failure in a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse should recognize that which assessment finding supports the presence of hypoxemia?

The client has circumoral cyanosis.

The client's heart rate is 86 bpm.

The client has a pulse ox of 90% on room air.

The client is lethargic.

Answer and Explanation

The Correct Answer is C

A. The client has circumoral cyanosis: Circumoral cyanosis, or bluish discoloration around the mouth, is a sign of hypoxia but may not be present in all cases of hypoxemia. Pulse oximetry provides a more objective measurement.

B. The client's heart rate is 86 bpm: Heart rate may be within normal limits even in the presence of hypoxemia, as compensatory mechanisms may not be fully activated.

C. The client has a pulse ox of 90% on room air: A pulse oximetry reading of 90% indicates hypoxemia (oxygen saturation below normal levels), which is a significant finding, especially in a client with COPD who may already have compromised respiratory function.

D. The client is lethargic: Lethargy may occur with severe hypoxemia, but it is a late sign and may not always be present. Monitoring oxygen saturation is more reliable for early detection of hypoxemia.

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Correct Answer is D

Explanation

A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.

B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.

C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.

D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin therapy.

A. Health care providers should be told about the diagnosis to deliver safe care. B. Most people in current society would be accepting of the diagnosis. C. Intimate partners should be told so they can protect themselves. D. The diagnosis is reportable to the state health department. E. Secrecy about the diagnosis is the privilege of the client.

Correct Answer is ["A","C","D"]

Explanation

A. Health care providers should be told about the diagnosis to deliver safe care: Health care providers need to know the client's diagnosis to provide appropriate and safe care. This includes administering medications, assessing for opportunistic infections, and implementing preventive measures.

B. Most people in current society would be accepting of the diagnosis: While stigma surrounding HIV/AIDS has decreased over time, disclosure is a personal decision, and not all individuals may be accepting of the diagnosis. Therefore, this statement may not always be accurate.

C. Intimate partners should be told so they can protect themselves: Disclosing the diagnosis to intimate partners is essential for their health and well-being, as it allows them to take necessary precautions to prevent transmission of the virus.

D. The diagnosis is reportable to the state health department: In many jurisdictions, HIV/AIDS diagnoses are reportable to the state health department for surveillance and public health monitoring purposes. This reporting is typically done without disclosing the client's identity.

E. Secrecy about the diagnosis is the privilege of the client: While confidentiality is crucial, it's important to balance it with public health considerations and the well-being of others who may be at risk of infection.

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A nurse suspects impending respiratory failure in a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse should recognize that which assessment finding supports the presence of hypoxemia?

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