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 C

Explanation

A. "I will be placing electrodes on your breasts": This statement is incorrect and may cause unnecessary concern or discomfort for the client. Electrodes for a 12-lead electrocardiogram are typically placed on the chest, not the breasts.

B. "I will lower the head of your bed so you can lie flat": This statement may be relevant for certain procedures but is not specific to applying electrode gel pads for a 12-lead electrocardiogram.

C. "Relax and try not to move or speak once I have attached the gel pads": This instruction is essential for obtaining a clear and accurate electrocardiogram recording. Movement or talking during the procedure can interfere with the quality of the tracing.

D. "Try to hold your breath until this procedure is complete": This instruction is unnecessary and could cause discomfort or anxiety for the client. There is no need for the client to hold their breath during a standard electrocardiogram procedure.

A. Sterilize dishes before using. B. Maintain good hygiene. C. Cook meats and fish well. D. Avoid consuming raw foods. E. Wash hands frequently

Correct Answer is ["B","C","D","E"]

Explanation

A. Sterilize dishes before using: This is not typically necessary. Washing dishes with hot water and soap or using a dishwasher is sufficient to ensure they are clean.

B. Maintain good hygiene: Good hygiene practices are crucial for immunocompromised individuals to prevent infections.

C. Cook meats and fish well: Properly cooking meats and fish helps to kill any harmful bacteria and parasites that could cause infections.

D. Avoid consuming raw foods: Raw foods, especially meats, eggs, and some vegetables, can harbor harmful bacteria and parasites, posing a risk of infection.

E. Wash hands frequently: Frequent handwashing is one of the most effective ways to prevent the spread of infections.

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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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Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client while applying the electrode gel pads?

Correct Answer is C

Explanation

A nurse is providing discharge instructions to a client who is severely immunocompromised by HIV. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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