A nurse is caring for a client who has COPD. The nurse should identify that which of the following findings is the priority to report?
Hgb 20 g/dL
Oxygen saturation 92%
Productive cough with green sputum
Chest x-ray shows hyperinflation of lungs
The Correct Answer is A
Answer: A
Rationale:
A) Hgb 20 g/dL:
A hemoglobin level of 20 g/dL is elevated and suggests polycythemia, which can occur in chronic respiratory conditions like COPD due to chronic hypoxia. Elevated hemoglobin levels can increase blood viscosity, leading to complications such as increased risk of thrombosis and cardiovascular stress. This finding indicates a potentially serious issue and should be reported to the healthcare provider immediately to address any underlying causes and manage the client's condition effectively.
B) Oxygen saturation 92%:
An oxygen saturation of 92% is slightly below the typical normal range (95-100%) but is not immediately life-threatening. While it indicates mild hypoxemia, it is a common finding in COPD patients, and the management would typically involve supplemental oxygen or adjustment of therapy. This finding should be monitored but is not the most critical issue to report immediately.
C) Productive cough with green sputum:
A productive cough with green sputum suggests a possible infection or exacerbation of COPD. Although this is an important finding that requires evaluation and possible treatment, it is less critical than an elevated hemoglobin level, which indicates a more acute systemic issue. The green sputum should be reported and managed, but it is not the priority compared to the elevated hemoglobin.
D) Chest x-ray shows hyperinflation of lungs:
Hyperinflation of the lungs is a common radiological finding in COPD due to air trapping. While it is a significant finding, it is generally consistent with the disease's progression and does not indicate an acute problem requiring immediate intervention. Monitoring and managing the underlying COPD are necessary, but this finding is less urgent than the elevated hemoglobin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Pull the auricle upward and outward.
Rationale:
A. Pull the auricle upward and outward:
Pulling the auricle upward and outward is the recommended technique for instilling ear drops in an adult. This method straightens the ear canal, allowing better access for the medication to reach the target area. It is essential for effective delivery and absorption of the otic suspension.
B. Pull the auricle downward and backward:
Pulling the auricle downward and backward is appropriate for children under three years old, as it aligns their shorter and straighter ear canal. In adults, this approach would not straighten the canal sufficiently for optimal medication instillation.
C. Pull the auricle upward and backward:
While pulling the auricle upward and backward can straighten the adult ear canal, the optimal direction to ensure the ear canal is fully open is upward and outward. This position allows the medication to reach deeper parts of the ear canal effectively.
D. Pull the auricle downward and outward:
Pulling the auricle downward and outward is not suitable for adults and does not provide the correct alignment for an adult ear canal. This technique is ineffective in reaching the canal's deeper parts in adult clients, thus limiting the efficacy of the medication.
Correct Answer is D
Explanation
Grapes are a common choking hazard for young children, especially toddlers, due to their small size, round shape, and slippery texture. The size and shape of grapes can block the airway and pose a significant risk if not properly cut or prepared before being given to a toddler. It is recommended to cut grapes into small pieces or slice them lengthwise to reduce the risk of choking.
While potatoes, corn, and oranges can also pose a choking risk if not properly prepared or cut into age-appropriate sizes, they are not as commonly associated with choking incidents in toddlers as grapes are. Nonetheless, it is essential for parents and caregivers to be aware of appropriate food preparation techniques and supervise children during meals to ensure their safety.
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