A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?

Pulse oximetry reading of 95%

Decreased depth of respirations

Flaring of the nostrils

Respiratory rate of 16/min

Answer and Explanation

The Correct Answer is C

A. Pulse oximetry reading of 95%. COPD clients often have lower baseline oxygen levels (88-92%), making this reading unexpectedly high.

B. Decreased depth of respirations. COPD typically causes shallow and rapid breathing due to air trapping.

C. Flaring of the nostrils: Nostril flaring is a sign of increased respiratory effort, which is common in COPD exacerbations.

D. Respiratory rate of 16/min. → Normal range (12-20/min), not an expected finding during dyspnea.

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Correct Answer is C

Explanation

A. Dry skin: More commonly associated with dehydration or skin conditions, not a direct response to stress.

B. Increased urinary output: Stress usually triggers the release of antidiuretic hormone (ADH), leading to decreased urinary output rather than an increase.

C. Dilated pupils: Stress activates the sympathetic nervous system (fight-or-flight response), leading to pupil dilation to enhance vision in a perceived emergency.

D. Hyperactive bowel sounds: Stress can affect digestion, but it is more commonly associated with nausea, not necessarily hyperactive bowel sounds.

A. Administer antibiotic therapy to the client. B. Provide the client with analgesics as needed. C. Initiate droplet precautions for the client. D. Educate the client about the meningococcal vaccine

Correct Answer is C

Explanation

A. Administer antibiotic therapy to the client. This is a priority intervention, but it is not the first action. Before administration, infection control measures should be in place.

B. Provide the client with analgesics as needed. Pain management is important but is not the first priority. The spread of infection must be controlled immediately.

C. Initiate droplet precautions for the client. Meningococcal meningitis is highly contagious. Droplet precautions (mask, private room) must be initiated immediately to prevent transmission before other interventions.

D. Educate the client about the meningococcal vaccine. Vaccination is a preventive measure but does not address the immediate risk of infection spread.

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A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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