A nurse is caring for a client who has COPD.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A Hydrogen peroxide can be too harsh and irritating to inflamed oral mucosa. It may further aggravate mucositis and delay healing. Therefore, it is not appropriate to recommend rinsing with hydrogen peroxide for a client with mucositis.
B. Brushing for 60 seconds is not enough.
C. Dentures can exacerbate mucositis by causing friction and pressure on the gums and oral mucosa. To reduce irritation, clients should remove dentures when not eating to give their gums and oral tissues a chance to rest and recover.
D. Flossing can help remove food particles and plaque from between the teeth, which could otherwise contribute to infection.
Correct Answer is C
Explanation
C. A bed alarm is a device that triggers an alert when the client attempts to get out of bed or leaves a designated area. Bed alarms can be effective in alerting nursing staff to the client's movements, allowing for timely intervention to prevent wandering and ensure the client's safety. This intervention is commonly used in healthcare settings to monitor clients at risk for falls or wandering.
A Moving the client to a double room may not necessarily prevent wandering. In fact, it could potentially increase the risk if the client wanders into another resident's space or attempts to leave the room altogether.
B. Using chemical restraints (such as medications to sedate or calm the client) is not recommended unless absolutely necessary for the safety of the client or others. It does not address the underlying cause of wandering and can have significant adverse effects on the client's health and well-being.
D. Providing excessive stimulation can overwhelm and agitate clients with dementia, potentially worsening behaviors such as wandering. It is important to offer activities that are calming, engaging, and appropriate for the client's cognitive abilities.
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