Exhibits
A nurse is reviewing the medical record of a client who has COPD. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Platelet count
Sputum color
Temperature
Fluid intake
The Correct Answer is C
A. Platelet count is normal (175,000/mm3) and does not require reporting to the provider.
B. Sputum color: While thick green sputum might suggest infection, the nurse should first assess for other clinical signs, and it might not need immediate reporting unless there are other concerns, like a change in respiratory status.
C. Temperature (38°C / 100.4°F) is elevated, which could indicate an infection, such as a respiratory infection or exacerbation of COPD. This finding should be reported to the provider because fever in a client with COPD could lead to complications like pneumonia or exacerbation of symptoms.
D. Fluid intake of 2,200 mL/24 hr is within normal limits and does not need reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).
B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.
C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.
D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.
E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.
Correct Answer is C
Explanation
A. WBC 13,000/mm3 is slightly elevated and might indicate an infection, but it is not critically high in the context of COPD. The nurse should still monitor the client for signs of infection but is unlikely to require immediate intervention.
B. Potassium 3.7 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not require reporting.
C. Hgb 20 g/dL is elevated and should be reported. High hemoglobin levels can indicate dehydration, polycythemia, or other conditions related to chronic hypoxia, which is common in COPD. This value is above the normal range (12–18 g/dL for adults) and requires further evaluation.
D. Iron 150 mcg/dL is within the normal range (50–170 mcg/dL for adults) and does not require reporting.
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