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?
Cough with clear sputum
Oxygen saturation of 95%
Respiratory rate of 28 breaths per minute
Mild dyspnea with activity
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Rhonchi are low-pitched, coarse sounds heard during both inspiration and expiration. They are typically associated with mucus or secretions in the larger airways and do not match the description of high-pitched squeaking sounds.
B. Wheezes are high-pitched, continuous sounds heard primarily during expiration. They result from narrowed airways, which are characteristic of asthma. The description provided matches wheezes, making this the correct documentation.
C. Stridor is a high-pitched sound heard predominantly during inspiration and is associated with upper airway obstruction. It does not match the description of sounds heard during exhalation.
D. Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli or smaller airways. They do not match the high-pitched squeaking sounds described.
Correct Answer is D
Explanation
A. Increasing fluid intake may help with hydration, but it is not the most appropriate intervention for a patient whose peak flow rates are significantly low. The priority is to address the asthma exacerbation.
B. Scheduling a follow-up appointment in two weeks is not appropriate in this situation. The patient is experiencing significant symptoms, and immediate action is required to manage the exacerbation.
C. Advising the patient to avoid all physical activity may not be necessary. Physical activity can be adjusted based on the patient's condition, but the priority is to treat the asthma exacerbation and improve the patient's respiratory status.
D. Initiating an asthma action plan and providing oral corticosteroids is the correct approach. A peak flow rate consistently at 45% of the personal best indicates poor asthma control, and the patient likely requires additional treatment, such as oral corticosteroids, to manage the exacerbation. The asthma action plan should guide further management based on the patient's peak flow rate and symptoms.
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