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

Answer and Explanation

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.

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

Explanation

A. Massaging the calves is incorrect. This action can dislodge a deep vein thrombus (DVT), increasing the risk of a pulmonary embolism.
B. Applying elastic compression stockings is correct. These help promote venous return, reducing the risk of blood stasis and clot formation.
C. Performing passive range of motion exercises is correct. These exercises prevent venous stasis, which is a major risk factor for DVT and PE.
D. Assessing legs for redness is correct. Redness, swelling, and warmth can indicate DVT formation, allowing for early intervention before it leads to PE.
E. Placing pillows under the client's knees is incorrect. This can impair circulation and increase the risk of clot formation by promoting venous stasis.

A. Encourage an increased intake of the client's favorite drink B. Continue to monitor daily weights and edema and document findings. C. Perform a head-to-toe assessment, including vital signs D. Check the record to determine code status

Correct Answer is C

Explanation

A. Encouraging increased fluid intake is incorrect. Clients with heart failure are at risk for fluid overload, and excessive fluid intake can worsen symptoms.
B. Simply monitoring and documenting findings is insufficient. A 2-pound weight gain in a short period suggests fluid retention and worsening heart failure, requiring further assessment and possible intervention.
C. Performing a head-to-toe assessment, including vital signs, is correct. The nurse should assess for worsening heart failure, including lung sounds (crackles), respiratory effort, blood pressure, and oxygen saturation, to determine if immediate interventions are needed.
D. Checking code status is not the priority. While knowing a client’s code status is important, the immediate concern is assessing for signs of fluid overload and potential decompensation.

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The nurse is assessing the client diagnosed with COPD. Which of the following would require immediate attention by the nurse?

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