A nurse is reviewing the medical record of a client who has COPD. The nurse should notify the provider about which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Temperature

Respiratory rate

SpO2

Answer and Explanation

The Correct Answer is C

A. Temperature: 37.2°C (99.0°F) is within the normal range.

B. Respiratory rate: 28/min is elevated but expected in COPD.

C. An SpO₂ of 88% indicates significant hypoxemia in a client with COPD, which requires immediate intervention. Oxygen therapy may be needed to maintain a target saturation of 88–92%.

D. pH: 7.22 indicates respiratory acidosis but is consistent with COPD and requires monitoring rather than immediate notification.

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Correct Answer is C

Explanation

A. "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick." – Incorrect. Symptoms of Lyme disease typically develop 3 to 30 days after a tick bite, not within 2 days.

B. "If bitten by a tick, testing for Lyme disease should occur within 2 weeks." – Incorrect. Testing immediately or within two weeks may yield a false-negative result because antibodies take time to develop. The CDC recommends waiting 4 to 6 weeks for accurate testing.

C. "Use a product with DEET on your skin and clothes when you are walking in a wooded area." – Correct. DEET is an effective tick repellent and should be applied to exposed skin and clothing to reduce the risk of tick bites, which can transmit Lyme disease.

D. "Remove embedded ticks by squeezing the body with tweezers." – Incorrect. The proper method for tick removal is to grasp it close to the skin with fine-tipped tweezers and pull straight out. Squeezing the tick’s body can cause it to release infectious fluids into the bite site, increasing the risk of disease transmission.

A. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves B. Performing a simple dressing change on a client's foot C. Providing postmortem care for a client who has recently died D. Washing hands with alcohol-based hard rub after bathing a client who has Clostridium difficile

Correct Answer is D

Explanation

A. Emptying an indwelling urinary catheter bag with clean gloves is appropriate and does not require intervention.

B. Performing a simple dressing change on a client’s foot is within the AP's scope of practice if the dressing is not complex or sterile.

C. Providing postmortem care is within the AP's role and does not require intervention unless specific contraindications exist.

D. Clostridium difficile (C. diff) spores are resistant to alcohol-based hand rubs. The AP must use soap and water for hand hygiene to effectively remove spores. This is an infection control breach that requires immediate intervention.

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A nurse is reviewing the medical record of a client who has COPD. The nurse should notify the provider about which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

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Naxlex Comprehensive Predictor Exams

A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program?

Correct Answer is C

Explanation

A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

Correct Answer is D

Explanation

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