A home health nurse is assessing a client who has COPD. Which of the following findings indicates the need for a referral for pulmonary rehabilitation?
Clubbing of the fingers
Pursed-lip breathing
Dyspnea at rest
Sa02; 92%
The Correct Answer is C
A. Clubbing of the fingers: Clubbing reflects long-term hypoxia and chronic lung disease progression, but it does not independently indicate the need for pulmonary rehabilitation. It is a structural change rather than a functional indicator of declining activity tolerance, so it does not guide referral decisions on its own.
B. Pursed-lip breathing: Pursed-lip breathing is a compensatory technique commonly used by clients with COPD to improve expiration and reduce air trapping. Its presence shows the client is already using adaptive methods, but it does not signal a new decline or a need for pulmonary rehabilitation.
C. Dyspnea at rest: Dyspnea at rest indicates significant functional impairment and poor exercise tolerance, which are key criteria for pulmonary rehabilitation referral. Pulmonary rehab helps clients who cannot maintain basic activity levels due to breathlessness by improving endurance, reducing dyspnea, and teaching energy-conservation strategies.
D. SaO₂ 92%: An oxygen saturation of 92% is common and generally acceptable in clients with COPD, as their baseline values are often lower than normal. This finding does not independently suggest declining function or worsening symptoms that would warrant a referral for pulmonary rehabilitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ensure one finger can be inserted between the vest and client's skin: Allowing one finger’s space prevents skin breakdown while maintaining proper immobilization. This ensures the vest is snug enough to stabilize the cervical spine but not so tight that it causes pressure ulcers or discomfort.
B. Use the halo device to turn the client in bed: The halo device is rigid and should never be used as a lever to move the client, as this can cause cervical spine injury. Turning and repositioning should be done by supporting the head, neck, and torso manually, not by pulling on the device.
C. Use a pen to itch under the vest: Inserting objects under the vest can damage the skin and increase the risk of infection or pressure injuries. Clients should be taught to relieve itching by gentle tapping or using approved tools outside the vest.
D. Tighten halo pins when loose: Halo pins should only be adjusted by a healthcare provider. Tightening pins independently can cause skull fractures, nerve injury, or increased pain, making this action unsafe for nursing practice.
Correct Answer is B
Explanation
A. Request a prescription for a nightly sedative.: Sedatives are not a first-line intervention for clients with dementia because they can increase confusion, fall risk, and adverse effects. Nonpharmacologic safety measures are preferred whenever possible.
B. Place the client's bed at the lowest height.: Keeping the bed at its lowest position reduces the risk of injury if the client attempts to get out of bed unassisted. This simple safety measure helps prevent falls, which are a major concern for clients with dementia.
C. Turn off all lights in the client's room at night.: Completely dark environments can increase disorientation and agitation in clients with dementia. Low-level lighting or nightlights is preferable to maintain orientation and safety.
D. Assist the client with toileting at least once every 4 hr.: While regular toileting is important, a 4-hour interval may not meet the client’s individual needs. Toileting schedules should be based on the client’s habits and signs of incontinence to prevent accidents.
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