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.
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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
A hemorrhagic brain attack (stroke) is less common than an ischemic brain attack. Ischemic strokes account for the majority of strokes.
Choice B rationale
Thrombolytic drugs are used to treat ischemic strokes, not hemorrhagic strokes. They do not cause hyper-reactive reflexes.
Choice C rationale
A hemorrhagic brain attack requires immediate intervention to prevent further damage. Hemorrhagic strokes involve bleeding in the brain, which can rapidly worsen and cause severe damage.
Choice D rationale
An ischemic brain attack is not necessarily less severe than a hemorrhagic brain attack. Both types of strokes are serious, but hemorrhagic strokes often require more urgent intervention due to the risk of ongoing bleeding.
Correct Answer is ["A","B","E","F"]
Explanation
Choice A rationale
The tripod position helps to improve breathing by allowing the diaphragm to expand more effectively. This position reduces the work of breathing and helps to increase lung capacity, which is beneficial for patients with emphysema.
Choice B rationale
Pursed lip breathing is a technique that helps to keep the airways open longer, allowing more air to escape and reducing the work of breathing. This method helps to improve ventilation and oxygenation in patients with emphysema.
Choice C rationale
Staying current with yearly vaccinations is important for overall health, but it is not a specific strategy for better breathing in emphysema patients. Vaccinations help prevent respiratory infections, which can exacerbate emphysema symptoms.
Choice D rationale
Taking an antihistamine every day is not a recommended strategy for better breathing in emphysema patients. Antihistamines are typically used to treat allergies and may have side effects that could worsen breathing difficulties.
Choice E rationale
Inhaling slowly and deeply helps to maximize lung expansion and improve oxygenation. This technique can help to reduce shortness of breath and improve overall breathing efficiency in patients with emphysema.
Choice F rationale
Sleeping with 2 pillows to prop oneself up helps to reduce the work of breathing by preventing the diaphragm from being compressed. This position can help to improve breathing and reduce shortness of breath during sleep.
Choice G rationale
Measuring peak flow is a useful tool for monitoring lung function, but it is not a specific strategy for better breathing in emphysema patients. Peak flow measurements can help to track the progression of the disease and adjust treatment plans accordingly.
Choice H rationale
Taking a leukotriene inhibitor every day is not a recommended strategy for better breathing in emphysema patients. Leukotriene inhibitors are typically used to treat asthma and may not be effective for emphysema.
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