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A nurse is caring for a client who has COPD.

Medication

Indacaterol 75 mcg, one inhalation daily

Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake

Select the 5 findings that require follow-up.

Disorientation

Barrel-shaped chest

Yellow sputum

Nebulizer use

Ankle edema

SaO2 92%

Clubbing of fingers

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Disorientation:

This may indicate a neurological or cognitive issue and requires further assessment.

B. Barrel-shaped chest:

This is a characteristic finding in COPD, but any change or worsening may need evaluation.

C. Yellow sputum:

Yellow or greenish sputum may indicate an infection, and follow-up is needed.

D. Nebulizer use:

Nebulizer use is part of the prescribed treatment.

E. Ankle edema:

Edema can be a sign of heart failure or other cardiovascular issues and should be investigated.

F. SaO2 92%:

Oxygen saturation of 92% is below the normal range. It may indicate respiratory compromise and needs attention.

G. Clubbing of fingers:

While clubbing can be associated with chronic respiratory conditions, it is not an immediate concern.

H. Lives alone:

Living alone may impact the client's support system but does not require immediate medical attention.

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Correct Answer is A

Explanation

A. Fatigue: Hypokalemia (low potassium levels) can lead to fatigue and weakness. Potassium is essential for proper muscle and nerve function, and a deficiency can result in muscle weakness and decreased energy levels.

B. Pitting edema: Pitting edema is more commonly associated with fluid retention, which can occur in heart failure. Hypokalemia is not typically a direct cause of pitting edema.

C. Dyspnea: Dyspnea (shortness of breath) is a symptom commonly associated with heart failure, and while potassium imbalance can affect cardiac function, it is not a specific manifestation of hypokalemia.

D. Oliguria: Oliguria (decreased urine output) is not a typical manifestation of hypokalemia. However, it can be associated with heart failure and other renal conditions.

A. Elevate the head of the bed 45". B. Keep the affected leg slightly flexed. C. Keep the client NPO for 4 hr. D. Have the client lie flat in bed.

Correct Answer is D

Explanation

Correct answer: D

A.Elevate the head of the bed 45":Do not elevate the head of the bed more than 15 degrees.Elevating the head of the bed can increase the risk of bleeding from the insertion site.

B.Keep the affected leg slightly flexed: The affected leg should be kept straight to prevent movement at the insertion site, which can cause bleeding

C. Keep the client NPO for 4 hr: There is typically no need to keep the client NPO for an extended period after a cardiac catheterization. However, individual protocols may vary, and the nurse should follow the specific instructions provided by the healthcare provider.

D.Have the client lie flat in bed: After a cardiac catheterization, it is important to keep the client lying flat to prevent bleeding or hematoma formation at the catheter insertion site. This position helps to maintain pressure on the insertion site, particularly if the catheter was inserted through the femoral artery.

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A nurse is caring for a client who has COPD. Medication Indacaterol 75 mcg, one inhalation daily Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake Select the 5 findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who has COPD.

Medication

Indacaterol 75 mcg, one inhalation daily

Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake

Select the 5 findings that require follow-up.