A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

Dyspnea

Barrel chest

Deep respirations

Clubbing of the fingers

Bradycardia

Answer and Explanation

Correct Answer : A,B,D

These findings are expected to be assessed in a client who has emphysema, which is a type of chronic obstructive pulmonary disease (COPD) characterized by destruction and enlargement of alveoli, loss of elastic recoil, and air trapping. These changes impair gas exchange and oxygenation, leading to chronic hypoxia and hypercapnia.

a) Dyspnea, or difficulty breathing, is a common symptom of emphysema, as the client has reduced lung capacity and increased work of breathing. Dyspnea may be worse with exertion, stress, or infection, and may cause anxiety and fatigue. The nurse should monitor the client's respiratory rate, rhythm, depth, and eﬀort, and provide oxygen therapy as prescribed.
b) Barrel chest, or increased anteroposterior diameter of the chest, is a physical sign of emphysema, as the client has chronic air trapping and hyperinﬂation of the lungs. Barrel chest may also cause kyphosis, or curvature of the spine, and reduced chest wall movement. The nurse should measure the client's chest circumference and observe for any deformities or asymmetry.
d) Clubbing of the fingers, or enlargement and rounding of the nail beds, is a late sign of emphysema, as the client has chronic hypoxia and tissue ischemia. Clubbing may also aﬀect the toes and ears, and may indicate pulmonary or cardiac disease. The nurse should inspect the client's nails for shape, color, angle, and capillary refill.

c) Deep respirations are not expected to be assessed in a client who has emphysema, as the client has shallow and rapid breathing due to air trapping and reduced lung compliance. Deep respirations may indicate other conditions, such as metabolic acidosis or anxiety. The nurse should assess the client's arterial blood gas levels and provide reassurance and relaxation techniques as needed.
e) Bradycardia, or slow heart rate, is not expected to be assessed in a client who has emphysema, as the client has tachycardia or normal heart rate due to hypoxia and increased sympathetic stimulation. Bradycardia may indicate other conditions, such as medication side eﬀects, vagal stimulation, or heart block. The nurse should monitor the client's pulse rate, rhythm, quality, and electrocardiogram as indicated.

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Correct Answer is C

Explanation

Placing the client in a prone position improves oxygenation and ventilation by reducing lung compression, increasing lung expansion, and redistributing blood ﬂow to better match ventilation.

a) Administering low-ﬂow oxygen via nasal cannula is not sufficient for a client with ARDS, who requires
high levels of oxygenation and positive pressure ventilation to prevent alveolar collapse and hypoxemia.
b) Oﬀering high-protein and high-carbohydrate foods frequently is beneficial for a client with ARDS, as it provides adequate nutrition and energy to support lung healing and prevent muscle wasting. However, it is not the priority intervention for improving respiratory function.
d) Encouraging oral intake of at least 3,000 mL of ﬂuids per day is contraindicated for a client with ARDS, who is at risk of ﬂuid overload and pulmonary edema. Fluid intake should be restricted and diuretics should be administered as prescribed to reduce ﬂuid accumulation in the lungs.

A. Observe for signs of infection B. Examine the skin for generalized urticaria C. Review laboratory test results for low hemoglobin D. Monitor the mouth for signs of xerostomia

Correct Answer is A

Explanation

Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.

Examine the skin for generalized urticaria. This is not a common side eﬀect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
Review laboratory test results for low hemoglobin. This is not a direct eﬀect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.

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A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

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