An admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds. These findings indicated the nurse to monitor the client for what?

Kyphosis and clubbing of the fingers

Dyspnea and hypoxemia

Sepsis and pneumothorax

Bradypnea and pursed-lip breathing

Answer and Explanation

The Correct Answer is C

A. Kyphosis and clubbing of the fingers:

Kyphosis refers to an excessive forward curvature of the spine, which is not directly related to diminished breath sounds. Clubbing of the fingers is often associated with chronic respiratory conditions, but it is not directly linked to the finding of diminished breath sounds.

B. Dyspnea and hypoxemia:

Dyspnea (shortness of breath) and hypoxemia (low oxygen levels in the blood) are common symptoms in COPD, but diminished breath sounds may indicate an additional concern, such as pneumothorax or other complications.

C. Sepsis and pneumothorax:

Diminished breath sounds can be a sign of pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse. Sepsis is a risk in clients with COPD due to the potential for respiratory infections. Monitoring for these complications is crucial.

D. Bradypnea and pursed-lip breathing:

Bradypnea (slow breathing) and pursed-lip breathing are coping mechanisms that individuals with COPD may use to manage their breathing difficulties. While they are relevant in the context of COPD, they are not directly associated with the finding of diminished breath sounds.

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Correct Answer is B

Explanation

A. Intermittent claudication:

Intermittent claudication is more commonly associated with peripheral arterial insufficiency rather than venous insufficiency. It is caused by inadequate blood flow to the muscles during activity, resulting in cramping or pain that typically resolves with rest.

B. Brownish discoloration to the legs:

Brownish discoloration to the legs, often referred to as hemosiderin staining, is a common finding in peripheral venous insufficiency. It occurs due to the breakdown of red blood cells and the deposition of hemosiderin in the tissues, especially around the ankles.

C. Weak or absent pedal pulses:

Weak or absent pedal pulses are more indicative of peripheral arterial insufficiency rather than venous insufficiency. Peripheral arterial disease can result in decreased blood flow to the extremities, leading to diminished pulses.

D. Unequal peripheral pulses between extremities:

Unequal peripheral pulses between extremities are also more suggestive of arterial insufficiency. Conditions such as atherosclerosis or arterial embolism can cause variations in pulses between different limbs.

A. Partial non-rebreathing mask B. Simple (Oxy Plus) mask C. Nasal cannula D. Non-rebreathing mask

Correct Answer is C

Explanation

A. Partial non-rebreathing mask:

This mask delivers higher concentrations of oxygen than a nasal cannula. It has a reservoir bag that allows the client to rebreathe some exhaled air, increasing the oxygen concentration delivered. However, it may not be necessary for a client with mild shortness of breath and slightly reduced oxygen saturation.

B. Simple (Oxy Plus) mask:

The simple mask provides a higher concentration of oxygen than a nasal cannula but lacks the reservoir bag found in the non-rebreathing mask. It is generally used for moderate oxygen needs. However, it might be more than what is required for a client with mild shortness of breath and slightly reduced oxygen saturation.

C. Nasal cannula:

Nasal cannulas are commonly used for clients with mild respiratory distress. They deliver a lower to moderate concentration of oxygen and are well-tolerated by most clients. They are suitable for individuals with mild shortness of breath and can be adjusted based on the required flow rate.

D. Non-rebreathing mask:

The non-rebreathing mask provides the highest concentration of oxygen among the options listed. It includes a reservoir bag to deliver a higher oxygen concentration. It is typically reserved for clients with higher oxygen requirements. For a client with mild shortness of breath and slightly reduced oxygen saturation, this may be more than necessary.

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An admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds. These findings indicated the nurse to monitor the client for what?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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