An admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds. These findings indicated the nurse to monitor the client for what?
Kyphosis and clubbing of the fingers
Dyspnea and hypoxemia
Sepsis and pneumothorax
Bradypnea and pursed-lip breathing
The Correct Answer is C
A. Kyphosis and clubbing of the fingers:
Kyphosis refers to an excessive forward curvature of the spine, which is not directly related to diminished breath sounds. Clubbing of the fingers is often associated with chronic respiratory conditions, but it is not directly linked to the finding of diminished breath sounds.
B. Dyspnea and hypoxemia:
Dyspnea (shortness of breath) and hypoxemia (low oxygen levels in the blood) are common symptoms in COPD, but diminished breath sounds may indicate an additional concern, such as pneumothorax or other complications.
C. Sepsis and pneumothorax:
Diminished breath sounds can be a sign of pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse. Sepsis is a risk in clients with COPD due to the potential for respiratory infections. Monitoring for these complications is crucial.
D. Bradypnea and pursed-lip breathing:
Bradypnea (slow breathing) and pursed-lip breathing are coping mechanisms that individuals with COPD may use to manage their breathing difficulties. While they are relevant in the context of COPD, they are not directly associated with the finding of diminished breath sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.75"]
Explanation
The nurse needs to calculate the correct dose of atropine for a client who has a prescription for 0.3 mg IV stat. The nurse knows that atropine is a medication that blocks the effects of the parasympathetic nervous system and is used to treat bradycardia, heart block, and some types of poisoning.
To find out how many milliliters of atropine the nurse will administer, the nurse can use the formula:
Dose ordered / Dose available = Volume to administer
Plugging in the values, the nurse gets:
0.3 mg / 0.4 mg per mL = 0.75 mL
Therefore, the nurse will administer 0.75 mL of atropine to the client IV stat.
Correct Answer is D
Explanation
A. Lie in a low Fowler’s or supine position:
Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.
B. Increase oral fluids unless contraindicated:
Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.
C. Increase activity:
Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.
D. Call the nurse for oral suctioning as needed:
This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.
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