The nurse is assessing the client diagnosed with COPD. Which of the following would require immediate attention by the nurse?
Use of accessory muscles during inspiration.
Large amounts of thick white sputum
Presence of a barrel chest and clubbing
Oxygen flowmeter set on 8 LPM
The Correct Answer is D
A. Use of accessory muscles during inspiration is common in COPD as clients work harder to breathe. While this indicates respiratory distress, it is not necessarily an immediate emergency.
B. Large amounts of thick white sputum can indicate mucus production, which is common in COPD. If the sputum were yellow or green, it could suggest infection, requiring further assessment.
C. A barrel chest and clubbing are chronic changes in COPD due to prolonged air trapping and hypoxia. These findings do not require immediate intervention.
D. Oxygen flowmeter set on 8 LPM is correct. High-flow oxygen can suppress the hypoxic drive in COPD clients, leading to respiratory depression. The nurse should immediately lower the oxygen to a safer level (typically 1-3 LPM) and monitor the client’s respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
- Obtain intravenous (IV) access: IV access is necessary for administering medications, fluids, and emergency interventions.
- Obtain the client's family history: While family history is important for long-term cardiac risk assessment, it is not a priority in the acute phase of chest pain management.
- Apply continuous ECG monitoring: Continuous ECG monitoring is critical for detecting arrhythmias, ischemic changes, and potential myocardial infarction (MI).
- Administer O₂ to maintain oxygen saturation greater than 90%: Oxygen therapy is indicated in clients with suspected MI if their oxygen saturation is below 90% to prevent further myocardial ischemia.
Correct Answer is A
Explanation
A. Preventing bronchospasms and promoting bronchodilation is correct. Ipratropium is an anticholinergic bronchodilator that relaxes airway muscles, reducing airway resistance and improving airflow in COPD patients.
B. Monitoring blood pressure is unrelated to ipratropium use. It primarily acts on the respiratory system, not the cardiovascular system.
C. Relieving nasal congestion is incorrect in this context, though ipratropium nasal spray can be used for rhinorrhea.
D. Reducing coughing is not the primary purpose. While bronchodilation may indirectly reduce cough by improving airflow, it is not a cough suppressant.
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