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. Add tap water as needed to the suction control chamber.
This is not the correct action. The suction control chamber of a water-seal chest tube drainage system is typically filled with sterile water to the prescribed level by the healthcare provider during the initial setup. Adding tap water to the suction control chamber can disrupt the balance of the system and affect the prescribed suction level. The nurse should not add tap water without specific instructions from the healthcare provider.
B. Maintain the drainage container below the level of the client's chest.
This is the correct action. In a water-seal chest tube drainage system, it's important to keep the drainage container below the level of the client's chest. This positioning allows gravity to assist in the drainage of air or fluid from the pleural space into the drainage container. It also helps prevent backflow of fluid or air into the chest cavity, ensuring the effectiveness of the drainage system.
C. Empty the collection container every shift.
While it may be necessary to empty the collection container if it becomes full, emptying it every shift is not a set rule. The frequency of emptying the collection container should be based on the volume of drainage and the facility's policy. The nurse should monitor the collection container regularly and empty it when it reaches the appropriate level, typically around half full or as indicated by facility protocol.
D. Clamp the chest tubes if it becomes disconnected.
Clamping the chest tubes if they become disconnected is not recommended. It can lead to tension pneumothorax, a life-threatening condition where air accumulates in the pleural space and compresses the lung. If a chest tube becomes disconnected, the nurse should immediately assess the situation, secure the chest tube connections, and notify the healthcare provider for further management.
Correct Answer is C
Explanation
A. "I'll rinse my mouth after taking this medication."
Montelukast is taken orally and is not associated with the risk of oral thrush or other mouth-related side effects that would require rinsing the mouth after administration. This action is more commonly associated with inhaled corticosteroids, not leukotriene receptor antagonists.
B. "I'll use this medication when I get an asthma attack."
Montelukast is not a rescue medication for asthma attacks. It is a long-term controller medication used to manage and prevent asthma symptoms, not to treat acute attacks. Short-acting bronchodilators such as albuterol are used for quick relief during asthma attacks.
C. "I'll take this medication once a day in the evening."
Montelukast is a leukotriene receptor antagonist commonly used to manage asthma. It is typically taken orally once daily, usually in the evening, to provide 24-hour control of asthma symptoms and improve lung function. Therefore, the statement indicating an understanding of the teaching is option C.
D. "I'll decrease my sodium intake while I'm taking this medication."
Montelukast is not known to affect sodium levels in the body or require any specific dietary modifications, such as decreasing sodium intake. Therefore, this statement is unrelated to the use of montelukast for asthma management
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