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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L are normal values, indicating no acidosis. Metabolic acidosis involves low pH and low bicarbonate, which this does not show, making it incorrect.

Choice B reason: pH 7.4 is normal, and HCO3- 35 mEq/L suggests metabolic alkalosis, not acidosis. Renal failure and diabetes typically cause acidosis due to acid accumulation, making this inconsistent with metabolic acidosis.

Choice C reason: pH 7.3 (low) and HCO3- 19 mEq/L (low) with normal PaCO2 indicate metabolic acidosis, common in renal failure due to impaired acid excretion and diabetic ketoacidosis, making this the correct choice.

Choice D reason: pH 7.45 and HCO3- 30 mEq/L suggest metabolic alkalosis, not acidosis. Elevated bicarbonate is opposite to the low levels expected in metabolic acidosis, making this incorrect for the patient’s condition.

A. Maintain complete bed rest B. Place light wrapping on the legs and waist C. Encourage early ambulation D. Put pillows under the knees

Correct Answer is C

Explanation

Choice A reason: Complete bed rest increases stasis, a risk factor for thrombus formation per Virchow’s triad. Immobility slows venous return, promoting clot development, making this choice counterproductive and incorrect for preventing postoperative thrombi.

Choice B reason: Light wrapping may provide comfort but does not effectively prevent thrombus formation. Compression stockings are preferred for venous return, and wrapping alone is insufficient, making this choice less effective than ambulation.

Choice C reason: Early ambulation promotes venous return, reducing stasis and preventing thrombus formation in postsurgical patients. It enhances circulation, countering Virchow’s triad, and is a standard intervention, making this the correct action to implement.

Choice D reason: Pillows under the knees cause venous pooling by flexing joints, increasing thrombus risk. This contradicts measures to enhance circulation, such as ambulation, making it an incorrect choice for thrombus prevention.

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The nurse is assessing a patient with chronic lung respiratory disease (COPD). Which assessment finding would be the most concerning finding?

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Naxlex Comprehensive Predictor Exams

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