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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The laboratory values are the same as the previous test values: This is unlikely in DIC. In an acute episode of DIC, there is usually a significant disturbance in coagulation values due to the consumption of clotting factors and the development of clotting abnormalities.
B. The laboratory values are within the expected reference range: In DIC, the coagulation values are usually not within the expected reference range. Instead, they are prolonged, reflecting the imbalance in the coagulation system.
C. The laboratory values are prolonged: This is the correct answer. In DIC, the PT, aPTT, and INR are prolonged because the coagulation factors are being consumed in the process of widespread clot formation.
D. The laboratory values are decreased: This is not typical for DIC. In DIC, the issue is not a decrease in clotting factors but rather their consumption, leading to an overall imbalance in the coagulation system.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today