A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?

The client has a respiratory rate of 28 breaths per minute.

The client has a temperature of 38°C (100.4°F).

The client has a blood pressure of 140/90 mmHg.

The client has a heart rate of 90 beats per minute.

Answer and Explanation

The Correct Answer is A

Choice A rationale
A respiratory rate of 28 breaths per minute indicates tachypnea, which is a sign of respiratory distress. Immediate intervention is needed to address the underlying cause and prevent further deterioration of the patient’s condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which may suggest an infection. While this requires medical attention, it is not as immediately critical as respiratory distress.
Choice C rationale
A blood pressure of 140/90 mmHg is considered high, but it does not indicate an immediate need for intervention in the context of COPD. Hypertension should be managed, but it is not an acute emergency.
Choice D rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate an immediate need for intervention. Monitoring the patient’s heart rate is important, but it is not an urgent concern in this scenario.

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Correct Answer is A

Explanation

Choice A rationale
A temperature of 38°C (100.4°F) and a stiff neck are classic signs of meningitis, indicating inflammation of the meninges.
Choice B rationale
Myocardial infarction typically presents with chest pain, not a stiff neck.
Choice C rationale
Appendicitis presents with abdominal pain, not a stiff neck.
Choice D rationale
Pneumonia presents with respiratory symptoms, not a stiff neck.

A. Bacterial infection. B. Viral infection. C. Fungal infection. D. Parasitic infection.

Correct Answer is A

Explanation

Choice A rationale
Bacterial infection often leads to an elevated white blood cell count (15,000/mm³) and fever (38.5°C). The body’s immune response to bacterial pathogens results in these clinical manifestations.
Choice B rationale
Viral infections can cause fever, but they typically do not lead to a significant increase in white blood cell count.
Choice C rationale
Fungal infections can cause fever and elevated white blood cell count, but they are less common and usually occur in immunocompromised individuals.
Choice D rationale
Parasitic infections can cause fever and elevated white blood cell count, but they are less common and usually present with other specific symptoms.

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A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with a temperature of 38°C (100.4°F) and a stiff neck. Which condition should the nurse suspect?

Correct Answer is A

Explanation

A nurse is assessing a client with a temperature of 38.5°C (101.3°F) and a white blood cell count of 15,000/mm³. Which condition is the client most likely experiencing?

Correct Answer is A

Explanation

A patient, who is on complete bed rest following extensive surgery, begins to complain of chest pain and shortness of breath with hemoptysis. His SO2 measures 90%. The nurse recognizes that the patient is most likely exhibiting signs and symptoms of which condition?

A nurse is assessing a client who presents with a temperature of 38°C (100.4°F), a heart rate of 110 beats per minute, and a blood pressure of 90/60 mmHg.Which condition is the client most likely experiencing?

A nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings is most concerning?

A nurse has identified a fluid volume deficit in the patient who has suffered prolonged vomiting and diarrhea. Which assessment data is most important in identifying that the patient may be developing prerenal acute kidney injury (AKI)?

A client with diabetes mellitus presents with a foot ulcer that is not healing. Which of the following factors could be contributing to the delayed healing?

Which assessment data would indicate to the nurse that pharmacologic treatment with antibiotics and antacids has been effective for the patient diagnosed with peptic ulcer disease (PUD) secondary to H. pylori?

A nurse is assessing a client with suspected meningitis. Which of the following signs would be most indicative of meningitis?

The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?