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 D
Explanation
A. Watery stool is not a typical sign of paralytic ileus; instead, bowel sounds are absent or hypoactive.
B. Oliguria (low urine output) is not directly related to paralytic ileus.
C. Dizziness is not a primary symptom of paralytic ileus.
D. This is the correct answer. Abdominal distention occurs due to the accumulation of gas and fluid in the intestines, which are unable to move due to ileus.
Correct Answer is D
Explanation
A. Place the client on an air mattress – While air mattresses help prevent pressure ulcers, they do not directly address mobility needs in the immediate postoperative period.
B. Rewrap the bandage every 8 hr in a circular pattern – The bandage should be reapplied more frequently (every 4–6 hr) using a figure-eight pattern to prevent restriction of circulation.
C. Turn the client every 4 hr while in bed – Clients should be turned at least every 2 hr to prevent pressure ulcers and improve circulation.
D. Instruct the client to use an overbed trapeze to move around in bed – This is the best intervention because it allows the client to reposition independently, reducing the risk of skin breakdown and enhancing mobility.
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