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
Enlarged liver (hepatomegaly) and peripheral edema are common clinical manifestations of right heart failure (RHF). RHF leads to congestion of systemic circulation, causing fluid accumulation in the liver and peripheral tissues.
Choice B rationale
Crackles in the lungs are more commonly associated with left-sided heart failure, where fluid backs up into the pulmonary circulation, leading to pulmonary edema.
Choice C rationale
A dry hacking cough is not a typical symptom of right heart failure. It is more commonly associated with respiratory conditions such as asthma or bronchitis.
Choice D rationale
Altered mentation with pinpoint pupils is not a characteristic of right heart failure. These symptoms are more indicative of neurological conditions or opioid overdose.

A. Hypertensive crisis. B. Migraine. C. Sinus infection. D. Gastroenteritis.

Correct Answer is A

Explanation

Choice A rationale
A hypertensive crisis is characterized by severely elevated blood pressure, which can cause severe headache and blurred vision due to increased intracranial pressure.
Choice B rationale
Migraines can cause severe headaches and visual disturbances, but in a patient with a history of hypertension, a hypertensive crisis is more likely.
Choice C rationale
Sinus infections can cause headaches and facial pain, but not typically blurred vision.
Choice D rationale
Gastroenteritis causes gastrointestinal symptoms like diarrhea and vomiting, not headaches and blurred vision.

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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?

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Naxlex Comprehensive Predictor Exams

Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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