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 A
Explanation
The correct answer is Choice A: Dull, aching calf pain.
Choice A rationale:
Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.
Choice B rationale:
Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.
Choice C rationale:
Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.
Choice D rationale:
Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.
Correct Answer is C
Explanation
The correct answer is C.
Choice A: Oxygen saturation of 95% The normal oxygen saturation level is between 95% and 100%. An oxygen saturation of 95% is within the normal range, so the nurse would not need to withhold furosemide for this reason.
Choice B: Serum sodium level of 140 mEq/L The normal serum sodium levels range from 135 to 145 mEq/L. A serum sodium level of 140 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.
Choice C: Blood pressure of 80/40 mm Hg Furosemide is a potent diuretic that can lead to a significant depletion of electrolytes, which may lead to side effects such as muscle cramps and an irregular heartbeat. Low blood pressure (hypotension) is a potential side effect of furosemide. Normal blood pressure for adults is typically around 120/80 mm Hg. A blood pressure reading of 80/40 mm Hg is considerably lower than the normal range, indicating hypotension.
Choice D: Serum potassium level of 4.8 mEq/L The normal serum potassium levels range from 3.6 to 5.2 mEq/L. A serum potassium level of 4.8 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.

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