A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?
Speaks in short phrases
Increased sputum production
Use of accessory muscles to breathe
Pulse oximetry reading of 90%
The Correct Answer is C
A. Speaking in short phrases can indicate increased effort or difficulty in breathing. While it suggests respiratory compromise, it is not an immediate concern unless it worsens or is accompanied by other severe symptoms.
B. Increased sputum production is common in clients with COPD and can indicate exacerbation or infection. It should be monitored closely but may not require immediate reporting unless it is severe or associated with other concerning symptoms.
C. This finding indicates increased respiratory effort and potential respiratory distress, which requires prompt attention and intervention.
D. A pulse oximetry reading of 90% indicates that the client's oxygen saturation is below the normal range but acceptable in client with COPD due to chronic hypoxemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This position, where the client is seated in a semi-upright sitting position, helps to reduce the risk of aspiration and facilitates breathing. It is also conducive to the proper functioning of the nasogastric tube for decompression.
B. Moistening the client's lips is also important for comfort, but it does not directly relate to the management of the nasogastric tube.
C. Sterile water should be used for irrigation only if the tube becomes clogged.
D. Measuring abdominal girth is important but not specific to nasogastric tube care.
Correct Answer is ["2"]
Explanation
To administer a dose of 10 mg of olanzapine using 5 mg tablets, the nurse would need to give two (2) tablets
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