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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dyspnea on exertion: Dyspnea on exertion is a common symptom in clients with heart failure and may indicate worsening heart function. While it warrants monitoring and potential intervention, it is not as urgent as rapid weight gain.
B. Increased urination: Increased urination may be expected with the use of diuretics, as they promote the excretion of excess fluid from the body. This finding is not typically concerning unless accompanied by other symptoms.
C. Weight gain of 2 pounds in a week: A weight gain of 2 pounds in a week may indicate fluid retention, but it is not as concerning as a rapid weight gain over a shorter period.
D. Weight gain of 3 pounds in 24 hours: A rapid weight gain of 3 pounds in 24 hours is significant and may indicate fluid overload, potentially leading to exacerbation of heart failure symptoms. It should be reported promptly to the healthcare provider for further evaluation and management.
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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