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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Oral candidiasis, also known as thrush, is a fungal infection of the mouth caused by Candida albicans. It is a common adverse effect of inhaled corticosteroids, such as fluticasone, which can suppress the normal flora of the oral cavity and create a favorable environment for fungal growth. It manifests as white patches or plaques on the tongue, palate, or cheeks that can be scraped off.
a) Polyuria, or excessive urination, is not an adverse effect of fluticasone. It can be caused by diabetes mellitus, diabetes insipidus, diuretics, or kidney disease.
b) Hypoglycemia, or low blood glucose level, is not an adverse effect of fluticasone. It can be caused by
insulin overdose, oral hypoglycemic agents, alcohol intake, or prolonged fasting.
c) Hypertension, or high blood pressure, is not an adverse effect of fluticasone. It can be caused by stress, obesity, smoking, salt intake, or kidney disease.
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