A nurse is admitting a client with an exacerbation of chronic obstructive pulmonary disease.
What signs would the nurse expect to observe with this client? Select all that apply.
A BMI greater than 30%.
Clubbing in upper digits.
AP chest diameter of 1:1.
Tripod positioning.
High amounts of energy.
Correct Answer : B,C,D
Clubbing in upper digits and tripod positioning are signs of chronic obstructive pulmonary disease (COPD), a respiratory disorder that has components of chronic bronchitis and emphysema. Clubbing is a thickening and widening of the fingertips and nails due to chronic low oxygen levels in the blood. Tripod positioning is when the person leans forward and supports their arms on a table or chair to facilitate breathing.
Choice A is wrong because a BMI greater than 30% indicates obesity, which is not a specific sign of COPD, although it can worsen the condition.
Choice C is wrong because AP chest diameter of 1:1 means that the chest is as wide as it is deep, which is also known as barrel chest. This is a sign of emphysema, one of the components of COPD, but not of COPD itself.
Choice E is wrong because high amounts of energy are not associated with COPD. On the contrary, people with COPD often experience fatigue, weakness, and reduced exercise tolerance due to impaired gas exchange and respiratory muscle function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
I should always have my breakfast ready to eat before injecting my morning insulin. This statement confirms that the client understands the importance of matching insulin administration with food intake to prevent hypoglycemia.
Choice A is wrong because hemoglobin A1C should be checked every 3 months, not monthly, to monitor long-term glycemic control.
Choice C is wrong because eating early and taking extra insulin later can cause fluctuations in blood glucose levels and increase the risk of complications.
Choice D is wrong because on sick days, the client should check blood sugar more
often and eat small amounts of carbohydrates to prevent hyperglycemia and ketoacidosis.
Correct Answer is C
Explanation
The proper length of the needle to administer a subcutaneous injection depends on the amount of adipose tissue over the muscle.
The needle should be long enough to reach the subcutaneous layer but not so long that it penetrates the muscle. The needle gauge and length vary depending on the patient’s size and the injection site
Choice A is wrong because the age of the client does not determine the needle length.
However, age may affect the amount of adipose tissue and muscle mass, which are factors to consider when choosing a needle length.
Choice B is wrong because the viscosity of the solution does not determine the needle length. However, viscosity may affect the needle gauge, which is the diameter of the needle.
Thicker solutions may require larger gauge needles to allow easier flow.
Choice D is wrong because the quantity of the solution does not determine the needle length.
However, quantity may affect the syringe size, which is the volume of medication that can be held by the syringe.
The syringe size should match the prescribed dose as closely as possible to ensure accuracy and ease of measurement.
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