A nurse is collecting data on a client who has COPD. Which of the following findings should the nurse expect?

A. Turn off the ventilator alarms before suctioning the client's airway.

This choice is incorrect because it goes against standard practice. Ventilator alarms are critical for monitoring the patient's respiratory status and detecting any issues with the ventilator or the patient's airway. Turning off alarms before suctioning can lead to missed alarms and potentially dangerous situations for the patient.

B. Provide mouth care every 10 to 12 hr with hydrogen peroxide.

This choice is incorrect because using hydrogen peroxide for mouth care is not recommended. Hydrogen peroxide can be irritating to the mucosa and may cause harm to the patient's oral tissues. Instead, gentle oral care with an appropriate solution, such as a mouthwash specifically designed for oral hygiene in ventilated patients, is preferred. Mouth care should also be provided more frequently than every 10 to 12 hours to maintain oral hygiene and prevent complications such as ventilator-associated pneumonia.

C. Place the head of the client's bed at 40° when supine.

This choice is correct. Proper positioning of the patient is crucial for optimizing ventilation and preventing complications such as aspiration and ventilator-associated pneumonia. Elevating the head of the bed to 40 degrees when the patient is in a supine position helps to minimize the risk of aspiration by promoting drainage of secretions away from the airway and improving lung expansion.

D. Reposition the client every 4 hr.

This choice is not directly related to care for clients receiving mechanical ventilation. While repositioning the patient every 4 hours is important for preventing pressure ulcers and maintaining skin integrity, it is not specific to mechanical ventilation care. However, it is still an important aspect of overall patient care, particularly for patients who are immobile or confined to bed for extended periods.

A. Inspiratory stridor

Inspiratory stridor is a high-pitched, musical sound heard during inspiration and is typically caused by turbulent airflow due to partial obstruction of the upper airway. It is commonly associated with conditions such as croup, epiglottitis, or anaphylaxis. While respiratory distress may occur in a pneumothorax, inspiratory stridor specifically suggests an upper airway obstruction rather than a pneumothorax.

B. Expiratory wheeze

Expiratory wheeze is a high-pitched, musical sound heard during expiration and is typically associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchiolitis. Wheezing occurs due to narrowing of the airways, leading to turbulent airflow during expiration. While a pneumothorax can cause respiratory distress, it is not typically associated with wheezing.

C. Absence of breath sounds

The absence of breath sounds over a particular area of the chest can indicate a pneumothorax. In a pneumothorax, air accumulates in the pleural space, causing partial or complete collapse of the lung and preventing it from making contact with the chest wall. This absence of breath sounds over the affected area is a classic finding in a pneumothorax and is crucial for its detection.

D. Coarse crackles

Coarse crackles are discontinuous, bubbling or popping sounds heard during inspiration and may be indicative of conditions such as pneumonia, pulmonary edema, or bronchiectasis. These crackles are typically heard when there is fluid or mucus in the airways. While a pneumothorax can cause respiratory distress, it does not typically produce crackles on auscultation.