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. A stage 3 pressure ulcer is characterized by full-thickness skin loss that may extend into the subcutaneous tissue layer but does not involve exposure of muscle, tendon, or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue as well.
B. This describes a stage 1 pressure ulcer. Stage 1 ulcers involve intact skin with non-blanchable redness, indicating potential damage to underlying tissue.
C. This describes a stage 2 pressure ulcer. Stage 2 ulcers involve partial-thickness loss of skin involving the epidermis and/or dermis, presenting as a shallow open ulcer or intact blister.
D. Accurately describes a stage 4 pressure ulcer.
Correct Answer is A
Explanation
A. Ginger is well-known for its ability to promote digestion. It can help alleviate nausea, improve gastric motility, and reduce bloating or discomfort associated with gastrointestinal issues such as a bowel obstruction. Therefore, the client's request for hot ginger tea likely aims to promote digestion, making option A a plausible choice.
B. Ginger is not typically used to regulate blood pressure. Its primary effects are related to digestion, anti- inflammatory properties, and potential immune system support, rather than directly affecting blood pressure regulation.
C. Ginger has anti-inflammatory properties, which can be beneficial in reducing inflammation in the body. However, in the context of the client's request for ginger tea after recovering from a bowel obstruction, the immediate purpose is more likely related to its digestive benefits rather than general anti- inflammatory effects.
D. Ginger has some antioxidant and immune-modulating properties that may contribute to enhancing the immune system. However, its use in Chinese culture, particularly as a tea, is traditionally more associated with digestive health rather than immune enhancement.
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