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

Respiratory rate

Temperature

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D","E"]

Explanation

Rationale:

A. Heart rate: Initially elevated (110/min), the client’s heart rate has decreased to 78/min by postpartum day 5, reflecting hemodynamic stability and resolution of infection-related tachycardia.

B. Temperature: Fever present on day 3 (38.6°C) has resolved by day 5 (37.1°C), indicating improved systemic response and reduced inflammation or infection.

C. WBC count: Markedly elevated at 33,000/mm³ on day 3, consistent with postpartum endometritis, has normalized to 10,000/mm³ by day 5, suggesting resolution of infection.

D. Fundal height: Uterine involution is progressing appropriately, moving from 1 cm above the umbilicus to 4 cm below by day 5, indicating the uterus is returning to its non-pregnant state.

E. Lochia: Lochia has changed from moderate, foul-smelling, dark brown on day 3 to a small amount of brownish-red with no odor by day 5, showing improvement in uterine healing and decreased infection.

F. Hemoglobin: The client’s hemoglobin has dropped from 11.1 g/dL to 10 g/dL. While still near the normal postpartum range, this decline does not represent an improvement and may indicate mild ongoing blood loss or dilutional effect.

A. Wear a dosimeter film badge to measure exposure. B. Discard bed linens from the client's room at the end of each day. C. Instruct visitors to remain 61 cm (2 feet) away from the client. D. Place a caution sign on the client's door. E. Don a lead apron when providing care.

Correct Answer is ["A","D","E"]

Explanation

Rationale:

A. Wear a dosimeter film badge to measure exposure: A dosimeter badge tracks the cumulative radiation exposure for healthcare workers. It is essential for staff safety when caring for clients with internal radiation therapy.

B. Discard bed linens from the client's room at the end of each day: Linens should not be discarded unless contaminated. They are usually kept in the room until radiation is removed to avoid unnecessary exposure to other staff or areas.

C. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should maintain a greater distance typically at least 6 feet (about 2 meters) and limit their visit time (usually to 30 minutes or less). Two feet is insufficient to minimize radiation exposure.

D. Place a caution sign on the client's door: Posting a radiation warning sign helps alert all personnel and visitors about radiation precautions, promoting safety and compliance with guidelines.

E. Don a lead apron when providing care: A lead apron protects the nurse from radiation exposure, especially when prolonged or close contact is necessary. It is a critical part of personal protective equipment in this setting.

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ExhibitsA 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.)

Nursing Test Bank

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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.)