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%

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Fever: Fever is a systemic sign of infection that may occur after peritonitis has progressed. While important to monitor, it is not typically the earliest indication of peritoneal infection in clients performing dialysis.

B. Cloudy effluent: Cloudy effluent is often the first sign of peritonitis in peritoneal dialysis clients. It reflects the presence of white blood cells or bacteria in the dialysate and allows early detection and prompt treatment of infection.

C. Generalized abdominal pain: Abdominal pain can occur with peritonitis, but it usually develops after the initial inflammatory process begins. Pain is a later manifestation compared with changes in dialysate appearance.

D. Increased heart rate: Tachycardia can be a secondary response to infection or systemic inflammation, but it does not serve as an early indicator. Monitoring effluent clarity provides the most immediate evidence of peritoneal infection.

A. Increased lung expansion B. Rapid, shallow respirations C. Crepitus at the puncture site D. Dry, nonproductive cough

Correct Answer is A

Explanation

A. Increased lung expansion: Thoracentesis removes excess fluid from the pleural space, allowing the affected lung to re-expand more fully. Improved lung expansion is an expected therapeutic outcome within a few hours after the procedure, leading to easier breathing and improved ventilation.

B. Rapid, shallow respirations: Rapid, shallow breathing may indicate respiratory distress or complications such as pneumothorax. This is not an expected finding and would require immediate evaluation. Its presence suggests impaired gas exchange rather than improvement after fluid removal.

C. Crepitus at the puncture site: Crepitus indicates subcutaneous emphysema, which can occur if air leaks into the tissue during the procedure. This is an abnormal finding and may signal a pneumothorax or injury to lung tissue, requiring prompt provider notification.

D. Dry, nonproductive cough: While a mild, transient cough may occur immediately after the procedure due to the change in intrathoracic pressure, a persistent or new, dry cough could indicate continued irritation or developing pleural complications, though less critical than the signs of pneumothorax.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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