A nurse is collecting data on a client who has COPD. Which of the following findings should the nurse expect?
Spoon nails
Peripheral edema
Pleural friction rub
Barrel chest
The Correct Answer is D
A. Spoon nails
Spoon nails, also known as koilonychia, refer to a concave or spoon-shaped deformity of the nails. This finding is associated with conditions such as iron deficiency anemia or certain systemic diseases, but it is not specifically associated with COPD.
B. Peripheral edema
Peripheral edema, or swelling of the extremities, is not a typical finding in COPD. It may occur in conditions such as heart failure, liver disease, or kidney disease, but it is not directly related to COPD unless there are comorbid conditions contributing to fluid retention.
C. Pleural friction rub
Pleural friction rub refers to a creaking or grating sound heard on auscultation of the lungs, typically during inspiration and expiration. It occurs when the inflamed pleural surfaces rub against each other. While pleural effusion (accumulation of fluid in the pleural space) may occur as a complication of COPD, pleural friction rub is not a typical finding in uncomplicated COPD.
D. Barrel chest
Barrel chest is a common finding in clients with COPD. It refers to an increased anterior-posterior diameter of the chest, giving it a rounded appearance similar to that of a barrel. This occurs due to hyperinflation of the lungs, which is characteristic of COPD, particularly in advanced stages. The hyperinflation leads to chronic air trapping and increased residual volume in the lungs, causing the chest to become enlarged and rounded.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the provider.
This choice suggests involving the healthcare provider immediately. While notifying the provider might eventually be necessary if the issue persists, it's not the initial action in this scenario. The nurse should first assess and troubleshoot the situation before escalating it to the provider.
B. Verify that the suction regulator is on.
This is the correct choice. When there is no bubbling in the suction control chamber of a chest tube, it may indicate that suction is not being applied properly. Verifying that the suction regulator is turned on and set to the correct level ensures that suction is being delivered to the chest tube.
C. Continue to monitor the client because this is an expected finding.
This choice is incorrect. The absence of bubbling in the suction control chamber is not an expected finding and suggests a potential problem with the suction system. Ignoring this finding without taking any action could lead to complications for the client.
D. Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Milking the chest tube is a technique used to maintain patency and promote drainage in chest tubes, but it should not be the first action when there is no bubbling in the suction control chamber. This action does not address the underlying issue of inadequate suction and may not be appropriate without first ensuring that suction is functioning correctly.
Correct Answer is C
Explanation
A. Muscle twitching
Muscle twitching is not a typical manifestation of oxygen toxicity. Instead, muscle twitching may be indicative of other conditions such as electrolyte imbalances (e.g., hypocalcemia or hypomagnesemia), neuromuscular disorders, or overstimulation of the nervous system.
B. Metallic taste in mouth
A metallic taste in the mouth is not commonly associated with oxygen toxicity. Instead, a metallic taste in the mouth may occur as a side effect of certain medications, dental issues, or as a symptom of other medical conditions such as acid reflux or oral infections.
C. Facial flushing
Facial flushing is a characteristic finding in oxygen toxicity. When exposed to high levels of oxygen over an extended period, individuals may experience facial flushing due to the vasodilatory effects of oxygen on blood vessels. This dilation of blood vessels leads to increased blood flow to the face, resulting in flushing or reddening of the skin.
D. Periorbital edema
Periorbital edema, or swelling around the eyes, is not a typical manifestation of oxygen toxicity. Instead, periorbital edema may occur as a result of various other conditions such as allergies, sinusitis, or fluid retention. It is not directly related to exposure to high levels of oxygen.
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