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 D
Explanation
Rationale:
A. "Initiate venous access with a 21-gauge needle." For blood transfusions, it is recommended to use a larger gauge needle, 18-20 gauge, to allow for proper blood flow and reduce the risk of hemolysis. A 21-gauge needle is too small for optimal transfusion.
B. "Obtain the client's first set of vital signs 1 hr after initiating the transfusion." The first set of vital signs should be obtained immediately before starting the transfusion, and then monitored every 15 minutes to detect any early signs of a transfusion reaction.
C. "Administer the unit of packed RBCs over 1 hr." The unit of packed RBCs should be administered over 4 hours to reduce the risk of transfusion reactions and allow for optimal oxygen-carrying capacity. Infusing blood too quickly can cause complications such as volume overload or reactions.
D. "Use Y tubing with 0.9% sodium chloride when administering the transfusion." Y tubing is commonly used for blood transfusions to allow for the infusion of normal saline (0.9% sodium chloride) alongside the blood product. This helps maintain the flow of the transfusion and reduces the risk of clot formation while flushing the line.
Correct Answer is A
Explanation
Rationale:
A. "I will use a mirror to inspect my feet daily." People with diabetes are at risk for nerve damage, which can lead to unnoticed foot injuries or infections. Using a mirror helps to inspect the feet daily and thoroughly, especially the soles, to prevent complications.
B. "I will eat a low residue diet." A low residue diet is not recommended for diabetes management. The focus for diabetic clients should be on balanced nutrition that controls blood glucose levels rather than restricting residue unless there are gastrointestinal issues.
C. "I will take my insulin 30 minutes before exercise." Taking insulin 30 minutes before exercise could increase the risk of hypoglycemia, especially if the exercise is vigorous. It is generally recommended to adjust insulin doses or carbohydrate intake depending on the type and intensity of the exercise, under the guidance of a healthcare provider.
D. "I will limit my fluid intake to 1 liter daily." Diabetes management does not involve limiting fluid intake unless there is a specific contraindication, such as kidney disease or heart failure. Adequate hydration is important for managing blood sugar levels and preventing dehydration.
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