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 A

Explanation

A. Orange slices: Orange slices should be avoided because they contain a fibrous membrane that can be difficult to chew and swallow, posing a choking risk. Additionally, the acidic nature of oranges may cause irritation in some clients.

B. Ground hamburger: Appropriate for a mechanical soft diet because it is easy to chew and swallow.

C. Cooked green beans: Softened through cooking, making them easy to chew.

D. Canned peaches: Soft and easy to chew, making them suitable for this diet.

A. Pull the fire alarm. B. Close the fire doors. C. Evacuate the room. D. Extinguish the fire.

Correct Answer is C

Explanation

A. Pull the fire alarm. While activating the alarm is crucial, the immediate priority is client safety, meaning evacuation comes first.

B. Close the fire doors. Closing doors helps contain the fire, but ensuring client safety is the priority.

C. Evacuate the room. According to the RACE (Rescue, Alarm, Contain, Extinguish) protocol, the first step is to Rescue clients in immediate danger, then pull the alarm.

D. Extinguish the fire. Attempting to put out the fire is only appropriate if the fire is small and manageable. If the fire is significant, evacuating clients takes precedence.

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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?

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