A nurse is collecting data from a client who has emphysema.
Which of the following findings should the nurse expect? (Select all that apply.).
Dyspnea.
Bradycardia.
Clubbing of the fingers.
Barrel chest.
Shallow respirations.
Correct Answer : A,C,D,E
Choice A rationale:
Dyspnea is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of the alveoli in the lungs, leading to difficulty breathing and shortness of breath. The loss of alveoli reduces the surface area for gas exchange, causing dyspnea.
Choice B rationale:
Bradycardia is not typically associated with emphysema. In fact, it is more common for clients with emphysema to have an increased heart rate (tachycardia) due to the body's compensatory response to low oxygen levels in the blood.
Choice C rationale:
Clubbing of the fingers is often seen in clients with chronic respiratory conditions like emphysema. It is a result of chronic hypoxia and is characterized by the abnormal rounding and thickening of the fingertips and nail beds.
Choice D rationale:
Barrel chest is a common physical finding in clients with emphysema. It is characterized by an increase in the anteroposterior diameter of the chest due to overinflation of the lungs. This change in chest shape is a result of chronic air trapping and hyperinflation, which are hallmarks of emphysema.
Choice E rationale:
Shallow respirations are expected in clients with emphysema. Due to the loss of alveolar elasticity and increased airway resistance, clients with emphysema tend to take shallow breaths, which are less effective for oxygen exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.
Choice B rationale:
Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.
Choice C rationale:
Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.
Choice D rationale:
"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Crackles in lung bases Crackles in the lung bases are often indicative of fluid accumulation in the lungs, which can occur in conditions like heart failure. These crackles are discontinuous and sound like "fine rales.”. They can be heard during inspiration and expiration.
Choice B rationale:
Periorbital edema Periorbital edema, or swelling around the eyes, can be a sign of fluid volume overload, especially in the context of an older adult receiving IV therapy. It suggests that excess fluid is accumulating in the body.
Choice D rationale:
Bounding radial pulse A bounding radial pulse is a sign of increased stroke volume and can occur when the heart is working harder to pump the increased blood volume associated with fluid overload.
Choice C rationale:
Swelling at the IV site Swelling at the IV site can be a local reaction and may not necessarily indicate fluid volume overload unless it is associated with other systemic signs.
Choice E rationale:
Flat neck veins when supine Flat neck veins when the client is supine are not typically associated with fluid volume overload. In fact, flat neck veins are more characteristic of hypovolemia. Now, let's address the final question.
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