A nurse working in the respiratory unit is caring for a client admitted for end stage COPD. Upon assessment the client's skin is pink, respirations are 13 bpm and saturations are 92% on 6 liters via nasal cannula. The client is complaining of shortness of breath while laying down. What should be the nurse's first priority action?

Retake the vital signs.

Call the health care provider.

Place the client in Fowler's position.

Increase the oxygen rate.

Answer and Explanation

The Correct Answer is C

A) Retake the vital signs:
While taking vital signs is important, the client’s vital signs (respiratory rate of 13 bpm, oxygen saturation of 92%, and normal skin color) suggest that there is no immediate crisis, such as a sudden drop in oxygen saturation or significant hemodynamic instability. Therefore, retaking the vital signs would not address the most urgent issue at the moment, which is the client's shortness of breath while laying down.

B) Call the healthcare provider:
Calling the healthcare provider may eventually be necessary if the patient's condition worsens or remains unrelieved after interventions. However, the first priority should be to manage the client’s immediate symptoms and improve their comfort. The client’s complaint of shortness of breath when lying down suggests that the positioning may be a contributing factor to their discomfort.

C) Place the client in Fowler's position:
The most appropriate first action for a client with end-stage COPD and shortness of breath while lying down is to place the client in Fowler's position. This position (sitting upright, typically at a 45-60° angle) helps to improve lung expansion and reduce the workload of breathing by using gravity to assist in lung ventilation. It also promotes diaphragmatic breathing, which can relieve the feeling of breathlessness.

D) Increase the oxygen rate:
The client is already on 6 liters of oxygen via nasal cannula and has an oxygen saturation of 92%, which is within an acceptable range for a patient with COPD. Increasing the oxygen rate further could risk causing oxygen toxicity or lead to CO2 retention in clients with COPD, as their respiratory drive is often driven by low oxygen levels rather than high carbon dioxide levels. Thus, increasing the oxygen rate should be done cautiously and only if clinically indicated by a healthcare provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Assessment findings	Expected Findings	Findings to be reported to provider
Barrel chest	✔️
Increased fatigue		✔️
Respiratory rate 40bpm		✔️
Thin appearance	✔️

Barrel chest: Expected Finding

Increased fatigue: Finding to be reported to the provider

Respiratory rate 40 bpm: Finding to be reported to the provider

Thin appearance: Expected Finding

Rationales:

Barrel chest – Expected Finding:

A barrel chest is a common physical finding in clients with chronic obstructive pulmonary disease (COPD), especially emphysema. It results from hyperinflation of the lungs over time, altering the shape of the chest wall.

Increased fatigue – Finding to be reported to the provider:

While COPD clients often experience fatigue, a sudden or unusual increase in fatigue may indicate worsening respiratory function or exacerbation of the disease. This finding requires further assessment and possible intervention to prevent complications.

Respiratory rate 40 bpm – Finding to be reported to the provider:

A respiratory rate of 40 bpm indicates significant tachypnea and respiratory distress. This finding, coupled with accessory muscle use, suggests the client may be experiencing an acute exacerbation of COPD or impending respiratory failure, which requires immediate provider notification.

Thin appearance – Expected Finding:

Clients with COPD often have a thin or cachectic appearance due to increased energy expenditure for breathing and reduced caloric intake. This is a typical finding in advanced COPD and does not require urgent reporting unless accompanied by other concerning symptoms.

A. The time between ventricular depolarization and repolarization (diastole) B. Time taken for impulse to spread to the point immediately preceding ventricular contraction C. Time taken for depolarization (contraction) of both ventricles (systole) D. Passage of electrical impulse through the atrium causing atrial depolarization

Correct Answer is D

Explanation

A) The time between ventricular depolarization and repolarization (diastole):
This refers to the period between ventricular depolarization and repolarization, which is associated with the QT interval on the EKG, not the P wave. The P wave specifically relates to atrial depolarization, not the ventricular activity. Diastole refers to the relaxation phase of the heart cycle, and it’s not directly linked to the P wave, which represents atrial contraction.

B) Time taken for impulse to spread to the point immediately preceding ventricular contraction:

The P wave represents the depolarization (or contraction) of the atria, not the time taken for the impulse to spread to the ventricles. The time taken for the impulse to spread through the atria, across the AV node, and down to the ventricles is better represented by the PR interval, not the P wave itself.

C) Time taken for depolarization (contraction) of both ventricles (systole):
This describes the QRS complex, which represents the depolarization (contraction) of the ventricles during systole, not the P wave. The QRS complex shows the electrical activity of the ventricles as they contract, while the P wave relates to atrial depolarization, which occurs before ventricular contraction.

D) Passage of electrical impulse through the atrium causing atrial depolarization:
The P wave represents the passage of the electrical impulse through the atria, leading to atrial depolarization. Depolarization of the atria results in the contraction of the atria, pushing blood into the ventricles. The P wave is the first part of the cardiac cycle on the EKG and reflects the electrical activity that causes atrial contraction.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

The patient asks the nurse what the P Wave indicates on an EKG strip. The nurse informs the patient that the P Wave represents:

Correct Answer is D

Explanation

A nurse working in the Neuro ICU is caring for a client who has been recently diagnosed with Guillain Barre Syndrome. Which of the following clinical manifestations should the nurse assess for?

A client with uterine cancer is being treated with internal radiation herapy (brachytherapy). What is the nurse's PRIORITY action when caring for this client?

A nurse is assessing a client who has been recently diagnosed with Bell's palsy. Which of the following findings should the nurse expect? [Select all that apply.]

A nurse is reviewing the EKG strip of a client who is hypertensive and is complaining of muscle weakness. Which of the following abnormalities on the clients EKG should the nurse interpret as a sign of hyperkalemia?

A client with a diagnosis of multiple sclerosis is scheduled to receive plasmapheresis treatments. A nurse explains to the client's spouse that the purpose of plasmapheresis is to:

A nurse assesses a client who presents to the provider's office to evaluate multiple nevi. Which finding should the nurse identify to the provider as possible sign of malignancy?

A client with the rhythm below has been admitted into the cardiac icu. What assessment finding does the nurse expect to find in this client?

How many milligrams of carbidopa is this patient taking per dose/tablet?