The nurse is caring for a client diagnosed with end-stage chronic obstructive pulmonary disease (COPD). Which of the following data warrants immediate intervention by the nurse?

Cough with clear sputum

Oxygen saturation of 95%

Respiratory rate of 28 breaths per minute

Mild dyspnea with activity

Answer and Explanation

The Correct Answer is C

A. A cough with clear sputum is a common symptom in COPD and does not warrant immediate intervention unless there is a change in the color, consistency, or amount of sputum, which could indicate infection.

B. An oxygen saturation of 95% is within normal limits for most individuals and is often acceptable for clients with COPD, as their target saturation is usually lower (88-92%) to avoid suppressing their hypoxic drive.

C. A respiratory rate of 28 breaths per minute indicates tachypnea, which suggests respiratory distress or worsening of the client’s condition. Immediate assessment and intervention are needed to prevent further deterioration.

D. Mild dyspnea with activity is a common symptom in clients with end-stage COPD and does not require immediate intervention unless it becomes severe or unrelieved with rest.

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Correct Answer is D

Explanation

A. Crepitus, or subcutaneous emphysema, near the insertion site can occur due to air leaking into the subcutaneous tissue. While it should be monitored, it does not always require immediate provider notification unless it is extensive or worsening.

B. The absence of visible eyelets indicates the chest tube is properly positioned within the pleural space. This is an expected finding and does not require provider notification.

C. Bubbling of the water in the water seal chamber with exhalation is normal in a client with a pneumothorax. It indicates air is being evacuated from the pleural space.

D. Movement of the trachea toward the unaffected side is a sign of tension pneumothorax, a life-threatening complication. This finding requires immediate notification of the provider and emergency intervention to relieve the pressure in the pleural space.

A. Ipratropium (Atrovent HFA) B. Albuterol (Proventil HFA) C. Salmeterol (Serevent Diskus) D. Montelukast (Singulair) E. Inhaled hypertonic saline

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

Explanation

A. Ipratropium (Atrovent HFA) is an anticholinergic medication that can be used in combination with short-acting beta-agonists like albuterol to help relieve bronchospasm during an acute asthma attack.

B. Albuterol (Proventil HFA) is a short-acting beta-agonist (SABA) that is commonly used as a first-line treatment during an acute asthma attack to rapidly relieve bronchoconstriction and improve airflow.

C. Salmeterol (Serevent Diskus) is a long-acting beta-agonist (LABA) used for long-term asthma control, not for acute exacerbations. LABAs are not effective in quickly relieving symptoms during an acute attack.

D. Montelukast (Singulair) is a leukotriene modifier used for long-term asthma management and prevention. It is not effective in treating acute asthma attacks.

E. Inhaled hypertonic saline can help in acute asthma attacks by increasing mucus clearance and improving respiratory function, especially in patients with severe symptoms.

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The nurse is caring for a client diagnosed with end-stage chronic obstructive pulmonary disease (COPD). Which of the following data warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

Which medications would be most appropriate to administer to a patient experiencing an acute asthma attack? Select all that apply.

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

Explanation

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