Exhibits
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 tabs for additional information about the client. There are three tabs that contain separate categories of data.)
SpO2
PH
Respiratory rate
Temperature
The Correct Answer is B
Rationale:
A. SpO₂: Although 88% is low for the general population, it is often an acceptable baseline for clients with COPD. Their oxygen saturation targets are typically between 88–92% to avoid suppressing respiratory drive, so this value may not require immediate provider notification.
B. pH: A pH of 7.22 indicates respiratory acidosis, which is a serious and potentially life-threatening complication of COPD. This level of acidosis shows that the client’s ventilation is inadequate, and immediate intervention is needed. This is the most critical finding that requires provider notification.
C. Respiratory rate: A rate of 22 breaths/min is slightly elevated but not critical. It may be compensatory and expected in a COPD patient who is hypoxic or retaining CO₂. By itself, it doesn't warrant urgent notification unless it worsens.
D. Temperature: A temperature of 37.2°C (99°F) is within the normal range and does not indicate infection or acute illness. It is not a finding that necessitates notifying the provider at this point.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "My home has running water and electricity": Access to utilities like water and electricity supports hygiene and food safety. This statement does not indicate a health risk and instead suggests a stable living environment.
B. “I wear a hat and long sleeves while I am working”: Wearing protective clothing helps reduce exposure to the sun, pesticides, and other environmental hazards, thereby promoting health and safety during outdoor labor.
C. “I am currently sharing my home with two roommates”: Sharing housing is common among migrant or seasonal workers. While crowding can pose a potential health risk, this specific scenario doesn’t indicate excessive crowding or direct danger.
D. “I eat vegetables directly from the field where I work”: Consuming unwashed produce from the field poses a significant risk for pesticide exposure and ingestion of harmful microbes. This practice is unsafe and could lead to acute or chronic health issues.
Correct Answer is B
Explanation
Rationale:
A. A client who reports a sudden onset of dizziness when sitting up: Although concerning, dizziness on position change may indicate orthostatic hypotension and is not immediately life-threatening. This client requires monitoring but is not the top priority based on airway or circulatory compromise.
B. A client who has new onset urticaria and angioedema: New urticaria and angioedema suggest a potential anaphylactic reaction, which can quickly progress to airway obstruction. This is a life-threatening emergency requiring immediate intervention to secure the airway and administer epinephrine.
C. A client who has numerous rectal polyps and blood-tinged stools: This condition could indicate a colorectal condition such as polyposis or malignancy, but it is not acutely life-threatening. The client needs evaluation, but not before those with airway or circulatory risks.
D. A client who has a subluxation of the fifth digit on the left foot: A subluxation is a partial dislocation, which can be painful but does not involve vital organ systems. This musculoskeletal issue is stable and can be addressed after more urgent needs are met.
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