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
pH
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Wire cutters – These are used in clients with wired jaws, not for chest tube management.
B. Tracheostomy tray – This is necessary for airway emergencies but is not specific to chest tube management.
C. Padded clamp – This is the correct answer because a padded clamp is used to assess for air leaks, check chest tube patency, or temporarily clamp the tube if needed during troubleshooting or before removal.
D. Sand bag – A sandbag is not necessary for a client with a chest tube; it is more commonly used for stabilizing orthopedic injuries.
Correct Answer is B
Explanation
A. Administer the medication subcutaneously – Diazepam should be given orally or intravenously in severe cases, not subcutaneously.
B. Initiate seizure precautions – This is the correct answer. Alcohol withdrawal can lead to seizures due to central nervous system hyperactivity. Diazepam, a benzodiazepine, is used to prevent seizures and manage withdrawal symptoms.
C. Administer the medication with an antacid – There is no need to administer diazepam with an antacid; doing so can interfere with absorption.
D. Initiate contact precautions – Alcohol withdrawal is not an infectious condition, so contact precautions are unnecessary.
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