The nurse is assessing a patient with chronic lung respiratory disease (COPD). Which assessment finding would be the most concerning finding?
Accessory muscle usage breathing
Increased anterior-posterior chest diameter (AP) chest diameter
Finger clubbing
Pulmonary edema
The Correct Answer is D
Choice A reason: Accessory muscle use is common in COPD due to airway obstruction, but it is not the most concerning. Pulmonary edema indicates acute fluid overload, a life-threatening complication requiring immediate intervention, making it a less critical finding in this context.
Choice B reason: Increased anterior-posterior chest diameter (barrel chest) is expected in chronic lung disease like COPD due to air trapping, not an acute concern. Pulmonary edema poses an immediate threat to oxygenation, making this a less urgent finding.
Choice C reason: Finger clubbing is a chronic sign of chronic lung disease, reflecting long-term hypoxia, but it is not acutely life-threatening. Pulmonary edema requires urgent treatment due to its impact on gas exchange, making clubbing less concerning.
Choice D reason: Pulmonary edema is the most concerning finding, as fluid in the lungs severely impairs oxygenation, risking respiratory failure in a COPD patient. This acute condition requires immediate intervention to restore gas exchange, making it the priority over chronic findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Applying the patch to the same site daily risks skin irritation and reduced absorption. Rotating sites (e.g., chest, arms) ensures efficacy, making this an incorrect instruction.
Choice B reason: Removing the nitroglycerin patch at night provides a nitrate-free period, reducing tolerance and maintaining efficacy. This is standard practice, making it the correct instruction for the client.
Choice C reason: Cutting the patch disrupts the controlled-release mechanism, causing unpredictable dosing and risks. Dizziness requires medical evaluation, not patch modification, making this incorrect and unsafe.
Choice D reason: Limiting application to the upper arm restricts options. Patches can be applied to hairless areas like the chest or back, making this unnecessarily restrictive and incorrect.
Correct Answer is A
Explanation
Choice A reason -year-old patient after a neck surgery: Log rolling is indicated for neck surgery patients to maintain spinal alignment, preventing injury to the surgical site or spinal cord. This technique ensures the neck and spine remain stable during repositioning, making it essential for this patient’s safety and recovery.
Choice B reason: A 68-year-old with hypostatic pneumonia does not require log rolling, as it primarily affects lung consolidation, not spinal stability. Standard repositioning to promote lung expansion is sufficient, making this technique unnecessary for this patient’s condition.
Choice C reason: An 84-year-old with a stage IV sacral pressure ulcer needs careful positioning to avoid pressure, but log rolling is not specifically indicated. Gentle repositioning with pressure relief is more appropriate, as spinal alignment is not a primary concern.
Choice D reason: A 54-year-old post-total knee replacement patient requires leg positioning to prevent dislocation, but not but log rolling not, which is specific for to spinal stability. Standard repositioning positioning with abduction devices is preferred, making making log rolling inappropriate for this patient.
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