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The nurse is caring for a client diagnosed with end-stage chronic obstructive pulmonary disease (COPD). Which of the following data warrants immediate intervention by the nurse?

A.

Cough with clear sputum

B.

Oxygen saturation of 95%

C.

Respiratory rate of 28 breaths per minute

D.

Mild dyspnea with activity

Answer and Explanation

The Correct Answer is C

A. A cough with clear sputum is a common symptom in COPD and does not warrant immediate intervention unless there is a change in the color, consistency, or amount of sputum, which could indicate infection.  

B. An oxygen saturation of 95% is within normal limits for most individuals and is often acceptable for clients with COPD, as their target saturation is usually lower (88-92%) to avoid suppressing their hypoxic drive.  

C. A respiratory rate of 28 breaths per minute indicates tachypnea, which suggests respiratory distress or worsening of the client’s condition. Immediate assessment and intervention are needed to prevent further deterioration.  

D. Mild dyspnea with activity is a common symptom in clients with end-stage COPD and does not require immediate intervention unless it becomes severe or unrelieved with rest.  


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Related Questions

Correct Answer is D

Explanation

A. Fluticasone is an inhaled corticosteroid often used to manage asthma. It does not pose a direct risk to a client with heart failure and asthma, so clarification is not needed for this medication.

B. Amoxicillin is an antibiotic and does not directly affect asthma or heart failure. It is not contraindicated in clients with these conditions, so clarification is not necessary.

C. Isosorbide dinitrate is a nitrate used to treat heart failure by reducing cardiac workload and improving oxygen delivery. It does not affect asthma and does not require clarification.

D. Carvedilol is a beta-blocker that is commonly used to manage heart failure, but it is a non-selective beta-blocker, which can exacerbate asthma symptoms by causing bronchoconstriction. In clients with a history of asthma, beta-1 selective blockers are preferred, so clarification of this order is necessary.

Correct Answer is ["0.8"]

Explanation

· Set up a proportion: (Desired dose) / (Available concentration) = (Amount to administer)

· Plug in the values: (3,800 units) / (5,000 units/mL) = X mL

· Solve for X: X = 3,800 / 5,000 X = 0.76 mL

· Round to the nearest tenth: X = 0.8 mL

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