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 B
Explanation
B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.
A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.
C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.
D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning
Correct Answer is C
Explanation
C. This statement highlights difficulty with a specific ADL (grooming) that OT can assess and intervene to improve independence and quality of life.
A Difficulty swallowing, preference for a wheelchair over a walker, and problems with bladder control may also require medical attention, but they are not directly related to the occupational therapy's primary focus on improving the patient's ability to perform daily activities
B. This statement suggests mobility issues and possibly difficulty with walking due to muscle weakness. While mobility aids such as wheelchairs and walkers are typically addressed by physical therapists, OT can also be involved in evaluating the client's preferences, abilities, and functional mobility needs.
D. While OT primarily focuses on ADLs and functional tasks, bladder control problems typically require evaluation and management by a urologist or specialist in urology.
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