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?
Dyspnea at rest
Pursed-lip breathing
Clubbing of the fingers
SP02 90%
The Correct Answer is A
Rationale:
A. Dyspnea at rest: Dyspnea at rest is a sign of advanced COPD, indicating that the client is experiencing significant respiratory difficulty. Pulmonary rehabilitation can help improve exercise tolerance and breathing, making this an appropriate reason for referral.
B. Pursed-lip breathing: Pursed-lip breathing is a technique often used by clients with COPD to help manage shortness of breath. It is not an indication for pulmonary rehabilitation, but rather a self-management strategy.
C. Clubbing of the fingers: Clubbing of the fingers can be a sign of chronic hypoxia and is commonly seen in advanced COPD. However, it does not directly indicate the need for pulmonary rehabilitation, although the condition may benefit from comprehensive care.
D. SPO2 90%: A SpO2 of 90% is low but not necessarily an indication for referral to pulmonary rehabilitation. It is important to monitor oxygen levels, but this alone does not trigger the need for rehabilitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Calculation:
Total volume to be infused = 500 mL.
Infusion time in minutes = 4 hr × 60 min/hr
= 240 minutes.
Drop factor of the manual IV tubing = 60 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)
= (500 mL × 60 gtt/mL) / 240 min
= 30000 / 240 gtt/min
= 125 gtt/min.
Answer: 125 gtt/min
Correct Answer is ["3300"]
Explanation
Calculation:
- Calculate the total volume from the continuous IV infusion over 24 hours.
Continuous infusion rate = 125 mL/hr
Time = 24 hr
Volume from continuous infusion = 125 mL/hr × 24 hr
= 3000 mL.
- Calculate the total volume from the cefazolin IV bolus over 24 hours.
Cefazolin bolus volume per dose = 50 mL
Frequency = every 4 hr
Number of doses in 24 hr = 24 hr / 4 hr/dose
= 6 doses.
Volume from cefazolin bolus = 50 mL/dose × 6 doses
= 300 mL.
- Calculate the total IV fluid intake over 24 hours.
Total IV fluid intake = Volume from continuous infusion + Volume from cefazolin bolus
= 3000 mL + 300 mL
= 3300 mL.
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