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A nurse is caring for a client who has COPD.

Exhibits

Click to highlight the findings below that require immediate follow-up.

Body System Findings

Neurological

Day 1:
Neurological

Client is oriented to person, place, and time. Client is restless. Pupils are reactive to light. Able to move all extremities.

Pulmonary

Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Oxygen saturation 87% on room air.

Cardiovascular Pulse 110/min. +2 pulses in all extremities.

Client is restless

tachypneic, cough is productive

mucous is yellow

Wheezes and crackles

Oxygen saturation 87% on room air

Pulse 110/min

oriented to person, place, and time

Able to move all extremities

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Restlessness can be a sign of inadequate oxygenation to the brain, known as hypoxia. This is particularly concerning in a client with COPD whose oxygen saturation is already low (87% on room air).

These pulmonary findings indicate worsening respiratory distress in a client with COPD. Tachypnea, productive cough with discolored sputum, and abnormal lung sounds (wheezes and crackles) suggest exacerbation of COPD. The oxygen saturation of 87% on room air is below normal (typically 95% or higher), indicating hypoxemia, which requires immediate assessment and intervention to prevent further respiratory compromise.

The elevated heart rate (110/min) may indicate increased workload on the heart due to respiratory distress and hypoxemia.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

D. Antithrombotic medications help to prevent the formation of new clots and keep existing clots from getting larger, which is crucial in the management of patients who have had an ischemic stroke.

A Opioid analgesics are used to relieve pain, typically moderate to severe pain. However, they are not routinely indicated as part of discharge therapy for clients who have had an ischemic stroke

B. Anticonvulsants are medications used to prevent or control seizures. They are not typically used as standard discharge medications for ischemic stroke

C. Diuretics are medications that promote diuresis (increased urine production) and are commonly used to manage conditions such as hypertension and congestive heart failure. They are not typically used as standard discharge medications for ischemic stroke

A. Administer prescribed corticosteroids. B. Slow infusion rate and contact the provider. C. Change infusion to lactated Ringer's and maintain rate. D. Lower the head of the bed to semi-Fowler's.

Correct Answer is B

Explanation

B. Slowing the infusion rate of 0.9% sodium chloride and contacting the provider are appropriate initial actions to manage the client's dyspnea and hypertension, which are likely due to fluid overload from the IV infusion.

A Corticosteroids are not typically indicated for dyspnea and hypertension related to IV fluid administration with 0.9% sodium chloride.

C Changing the type of IV fluid to lactated Ringer's solution may be considered in some cases to address fluid balance issues. However, this decision should be made in consultation with the healthcare provider based on the client's specific clinical condition and fluid status.

D. Lowering the head of the bed to semi-Fowler's position can help improve respiratory function and reduce dyspnea. However, this action alone does not address the underlying cause of the client's symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?

Exhibits The nurse should plan to first administer dropdown followed by dropdown

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