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%

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Place the client in a high Fowler's position:High Fowler’s would increase intra-abdominal pressure and strain sutures. For peritonitis recovery, semi-Fowler’s is preferred-promotes drainage of peritoneal fluid into the pelvis, preventing spread to diaphragm and lungs.

B. Ambulate the client twice daily:Too early after peritonitis lavage. Initially, the client is very weak, at risk for sepsis/shock. Early ambulation is not a priority here.

C. Mark abdominal girth once daily:Abdominal girth measurement is important to monitor for distention, fluid accumulation, or bleeding. Marking ensures accuracy in repeated measurements. This is a key intervention in monitoring postop peritonitis.

D. Irrigate the nasogastric tube with tap water:Never irrigate with tap water (risk of electrolyte imbalance, infection). Only sterile normal saline or as prescribed is used.

A. Bananas B. Cheddar cheese C. White rice D. Cabbage

Correct Answer is A

Explanation

A. Bananas are a good source of potassium. They contain approximately 422 mg of potassium per medium-sized banana. Including bananas in the diet can help replenish potassium levels in clients who are at risk of hypokalemia due to medications like furosemide.
B. Cheddar cheese is not a significant source of potassium. It contains only trace amounts of potassium. Therefore, it would not be beneficial for increasing potassium levels.
C. White rice is very low in potassium. It does not contribute significantly to potassium intake. Therefore, it would not be helpful for addressing hypokalemia.
D. Cabbage is also low in potassium. While it has some nutritional value, it does not provide a significant amount of potassium compared to other foods.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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