A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

Oxygen saturation level 96%

Respiratory alkalosis

Increased anteroposterior diameter of the chest

Petechiae on chest

Answer and Explanation

The Correct Answer is C

Increased anteroposterior diameter of the chest, also known as barrel chest, is a common finding in clients who have COPD with emphysema. It is caused by chronic air trapping and hyperinﬂation of the lungs, which results in fattening of the diaphragm and widening of the rib cage.

a) Oxygen saturation level 96% is within the normal range of 95% to 100% and does not indicate hypoxemia or impaired gas exchange. Clients who have COPD with emphysema typically have lower oxygen saturation levels, ranging from 88% to 92%.
b) Respiratory alkalosis is a condition in which the blood pH is elevated due to decreased carbon dioxide levels. It is caused by hyperventilation, which can occur in response to hypoxia, anxiety, or pain. Clients who have COPD with emphysema usually have respiratory acidosis, which is a condition in which the blood pH is lowered due to increased carbon dioxide levels. It is caused by hypoventilation, which results from impaired lung function and airway obstruction.
d) Petechiae on chest are small red or purple spots on the skin caused by bleeding from capillaries. They are not a typical finding in clients who have COPD with emphysema, unless they have severe coughing episodes or coagulation disorders. They can indicate infection, inﬂammation, trauma, or vascular disease.

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Correct Answer is ["A","C","E"]

Explanation

These clients have impaired swallowing, gag reﬂex, or level of consciousness, which increase their risk of aspiration while eating.

The other options are not correct because:

b. A client who has had prolonged diarrhea does not have a direct risk factor for aspiration, as diarrhea aﬀects the lower gastrointestinal tract and not the upper airway or esophagus.

d. A client who has lactose intolerance does not have a risk factor for aspiration, as lactose intolerance causes abdominal cramps, bloating, gas, or diarrhea when consuming dairy products, but does not aﬀect the ability to swallow or protect the airway.

A. The medication will prevent wheezing. B. The medication will decrease coughing episodes. C. The medication will reduce inﬂammation. D. The medication will open the airways. E. The medication will stimulate ﬂow of mucus.

Correct Answer is ["A","B","D"]

Explanation

Answer: A, B D

Rationale:

Albuterol is a bronchodilator, and one of its key effects is to relax the muscles around the airways, which helps prevent wheezing. Wheezing is often caused by narrowed airways, and by opening them, albuterol helps to prevent this sound, which is associated with asthma or other respiratory conditions.
B. The medication will decrease coughing episodes:
Albuterol can help decrease coughing in individuals with conditions like asthma or chronic obstructive pulmonary disease (COPD) by relaxing the muscles in the airways, which reduces airway constriction. Since coughing often occurs due to airway obstruction, albuterol’s bronchodilator effect can help alleviate this symptom.
C. The medication will reduce inflammation: Albuterol does not have anti-inflammatory properties. Its primary mechanism is bronchodilation, and anti-inflammatory treatment generally requires corticosteroids, not beta-agonists like albuterol.
D. The medication will open the airways:
This is correct. Albuterol works as a bronchodilator, meaning it opens up the airways by relaxing the smooth muscles surrounding them. This improves airflow and makes breathing easier, which is why it is often used in conditions like asthma or COPD.
E. The medication will stimulate flow of mucus: Albuterol does not stimulate mucus production; it primarily works by relaxing the airways. However, by improving airflow, it can help clients more effectively expel mucus through coughing.

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A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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