Read the client scenario and answer question.
COPD patient's chart - Nurse's Note (0800) 84-year-old male client with a chronic obstructive pulmonary disease (emphysema) history is admitted to the inpatient Med surge unit provider today. Upon admission, the client reports unusual increased shortness of breath and fatigue. The client is on 1 liter of oxygen via a nasal cannula; 02 saturation is 93%. The client's respiratory rate is 30 bpm with accessory muscle use, heart rate is 125 bpm, and blood pressure is 127/89 mmHg. The client has a barrel chest and extremities. On call provided paged, pending call back.
Identify listed assessment findings as expected or findings that need to be reported to the provider. Select only one answer per finding.
Barrel chest
Increased fatigue
Respiratory rate 40bpm
Thin appearance
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
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Assessment findings
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Expected Findings
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Findings to be reported to provider
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Barrel chest
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✔️ |
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Increased fatigue |
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✔️ |
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Respiratory rate 40bpm
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✔️ |
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Thin appearance
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✔️ |
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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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 250 mg:
This represents the amount of levodopa in the tablet, not carbidopa. Sinemet contains two active ingredients: carbidopa (25 mg) and levodopa (250 mg), as shown on the label.
B. 25 mg:
This is the correct answer, as the label indicates that each tablet contains 25 mg of carbidopa. Carbidopa is combined with levodopa to improve its effectiveness and reduce side effects like nausea.
C. 5 mg:
This is not accurate; the label clearly states that the carbidopa dose is 25 mg per tablet.
D. 200 mg:
This does not correspond to the dose of carbidopa or levodopa in this medication. The label specifies 25 mg of carbidopa and 250 mg of levodopa.
Correct Answer is A
Explanation
A) Wear a dosimeter badge and lead apron when providing direct patient care: When caring for a patient undergoing internal radiation therapy (brachytherapy), radiation safety is the nurse’s priority. The nurse must take measures to minimize radiation exposure by wearing protective equipment such as a dosimeter badge (to monitor exposure levels) and a lead apron (to shield against radiation). These precautions are critical to protect healthcare workers from potential radiation harm while caring for a patient with a radiation implant.
B) Avoid placing a radiation sign at the entrance of the room for patient privacy: Placing a radiation warning sign at the entrance of the room is a mandatory safety protocol when a patient is undergoing brachytherapy. This warning sign informs healthcare personnel and visitors that radiation is present, and it is important for ensuring safety. Patient privacy should not override radiation safety protocols.
C) Alert family members that they should restrict their visiting to 60 minutes at a time: While it is essential to inform family members about safety precautions when visiting a patient receiving radiation therapy, the priority action for the nurse is to ensure their own safety and radiation exposure first. Limiting family visits is an important step to reduce unnecessary exposure, but this is a secondary concern compared to the nurse's direct radiation safety measures.
D) Explain to the patient that she will continue to emit radiation for months after the implant is removed: The patient will continue emitting radiation only for a short period after the implant is removed. The duration of radiation emission depends on the type of radioactive material used in brachytherapy, but it is typically limited to a few days or weeks at most. In most cases, the nurse would explain to the patient that, after the implant is removed, radiation emission will cease.
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