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 C
Explanation
A. Docusate Sodium (Colace) is a stool softener and is not contraindicated in chronic renal disease.
B. Acetaminophen (Tylenol) is generally safe for use in chronic renal disease, but dosing adjustments may be necessary based on renal function.
C. Meperidine (Demerol) is contraindicated in clients with chronic renal disease because its metabolites can accumulate in renal impairment, leading to neurotoxicity and seizures. It is often replaced with alternative opioid analgesics like morphine or fentanyl in these patients.
D. Atorvastatin (Lipitor) is a statin medication used to lower cholesterol levels and is generally safe in chronic renal disease, although dosing adjustments may be needed depending on the severity of renal impairment.
Correct Answer is A
Explanation
A. Administration of erythropoietin (Epoetin): In chronic renal disease, the kidneys may not produce enough erythropoietin, leading to anemia. Epoetin is a synthetic form of erythropoietin that stimulates red blood cell production and is commonly used to treat anemia in these clients.
B. Transfusion of red blood cells (RBCs): While transfusion of RBCs may be necessary in severe cases of anemia or acute blood loss, it is not the first-line treatment for anemia related to chronic renal disease. Erythropoietin-stimulating agents are preferred to stimulate endogenous RBC production.
C. Weekly monitoring of complete blood count (CBC): Monitoring of CBC is important to assess the response to treatment and adjust therapy as needed but does not represent a specific treatment for anemia in chronic renal disease.
D. An order for iron replacement medication: Iron replacement may be indicated if iron deficiency is contributing to the anemia, but it is not the primary treatment for anemia in chronic renal disease. Erythropoietin-stimulating agents are typically used first to address the underlying cause of anemia.
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