A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department reporting shortness of breath on minimal exertion. Which assessment finding by the nurse would be most important to report to the health care provider?

The patient is sitting in the tripod position.

The patient’s pulse oximetry shows a 90% O2 saturation.

The patient has bibasilar lung crackles.

The patient’s respiratory rate is 9 breaths/min.

Answer and Explanation

The Correct Answer is D

Choice A reason: Tripod position aids breathing in COPD by stabilizing accessory muscles, a common adaptation. It signals distress but isn’t immediately life-threatening compared to respiratory rate, as it reflects chronic compensation rather than acute decompensation requiring urgent intervention.

Choice B reason: O2 saturation of 90% is low but typical in COPD due to ventilation-perfusion mismatch. It warrants monitoring, yet it’s less critical than respiratory rate, as supplemental oxygen can correct it, and it’s not an immediate danger sign.

Choice C reason: Bibasilar crackles suggest fluid or infection, uncommon in pure COPD exacerbations, which show wheezing. This finding needs attention but is less urgent than respiratory rate, as it may indicate pneumonia rather than immediate respiratory failure.

Choice D reason: Respiratory rate of 9 breaths/min is alarmingly low in COPD, where tachypnea (20-30 breaths/min) is expected during exacerbation. Bradypnea indicates potential respiratory depression or fatigue, risking CO2 retention and hypoxia, necessitating immediate reporting for intervention.

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Correct Answer is A

Explanation

Choice A reason: Auscultating lung sounds post-albuterol assesses treatment efficacy in asthma exacerbation. Reduced wheezing or improved air entry indicates bronchodilation, guiding further care, making it the priority to evaluate respiratory response immediately.

Choice B reason: Measuring temperature monitors infection, a possible asthma trigger, but it’s not the priority post-treatment. Albuterol targets acute bronchospasm, so assessing respiratory effect trumps systemic checks like fever in this moment.

Choice C reason: Encouraging ambulation is premature post-albuterol; patients need rest during exacerbation. It risks worsening dyspnea before confirming treatment success, making it less urgent than evaluating lung response to the bronchodilator.

Choice D reason: Documentation is essential but secondary to patient assessment post-treatment. Auscultating lung sounds first ensures albuterol’s effect is evaluated, as clinical response guides care before recording in the record.

A. Give the PRN acetaminophen (Tylenol). B. Notify the health care provider of these findings. C. Obtain oxygen saturation using pulse oximetry. D. Give the scheduled IV antibiotic.

Correct Answer is B

Explanation

Choice A reason: Acetaminophen reduces fever, but 101.2°F isn’t critical in sepsis, where hypotension (90/56 mmHg) signals shock. Addressing fever alone ignores systemic instability, delaying urgent intervention for a deteriorating patient needing comprehensive management.

Choice B reason: Hypotension (90/56 mmHg) and tachypnea (34 breaths/min) indicate septic shock, requiring immediate escalation. Notifying the provider ensures rapid fluid resuscitation and vasopressors, critical in gram-negative sepsis to reverse hypoperfusion and prevent organ failure.

Choice C reason: Pulse oximetry assesses oxygenation, useful in sepsis with tachypnea. However, hypotension is more immediately life-threatening, prioritizing provider notification for systemic treatment over a single parameter check that delays broader stabilization efforts.

Choice D reason: IV antibiotics target sepsis’s cause, but a scheduled dose doesn’t address acute hypotension urgency. Provider notification supersedes routine administration, as shock requires fluids and pressors now, not just infection control, to save the patient.

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A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department reporting shortness of breath on minimal exertion. Which assessment finding by the nurse would be most important to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Sara is receiving a nebulized albuterol treatment for her asthma exacerbation. Which of the following should be the nurse’s first priority after administering the treatment?

Correct Answer is A

Explanation

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

Correct Answer is B

Explanation

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