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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 D

Explanation

A. Wearing loose, non-constricting stockings: This instruction is not recommended for a client with DVT. Compression stockings, which are snug-fitting, may be prescribed to prevent DVT, but loose stockings would not provide the necessary compression.

B. Applying cool compresses to her legs: Cool compresses are not typically recommended for DVT. Warm compresses may be used to improve blood circulation, but cold compresses may not be suitable.

C. Taking an NSAID tablet daily: Nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically recommended for individuals with DVT, especially when on anticoagulant therapy, as they may increase the risk of bleeding.

D. Flexing her knees and feet frequently: This is the correct answer. Encouraging the client to flex her knees and feet frequently helps promote blood circulation and reduces the risk of venous stasis, which can contribute to the formation of blood clots. It is a beneficial measure for clients with DVT.

A. Myringotomy B. Hip arthroplasty C. Cataract extraction D. Laparoscopic appendectomy

Correct Answer is B

Explanation

A. Myringotomy: Myringotomy is a procedure involving the insertion of tubes into the eardrum to treat conditions such as chronic ear infections. This procedure is not associated with a significant risk of deep-vein thrombosis.

B. Hip arthroplasty: Hip arthroplasty, or hip replacement surgery, is associated with an increased risk of deep-vein thrombosis due to factors such as immobility, surgical trauma, and alterations in blood flow. Prophylactic measures, such as anticoagulant medications and early ambulation, are often employed to reduce this risk.

C. Cataract extraction: Cataract extraction is a procedure to remove a cloudy lens from the eye. This surgery is not typically associated with a high risk of deep-vein thrombosis.

D. Laparoscopic appendectomy: Laparoscopic appendectomy, a minimally invasive procedure to remove the appendix, is generally associated with a lower risk of deep-vein thrombosis compared to major orthopedic surgeries like hip arthroplasty.

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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

A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

Correct Answer is B

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.