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 C
Explanation
A. While anxiety can cause rapid breathing and confusion, the patient's clinical presentation (dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation) is more consistent with a serious physical condition, such as a pulmonary embolism, rather than an anxiety attack.
B. Pneumonia could cause dyspnea and confusion, but the rapid onset of symptoms, along with the patient's history of prolonged bed rest and risk factors, suggests a pulmonary embolism rather than pneumonia.
C. Pulmonary embolism (PE) is a life-threatening condition that can occur in patients on prolonged bedrest, especially after a pelvic fracture. The patient’s symptoms of dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation are classic signs of PE. This requires immediate intervention, including anticoagulation and possibly thrombolytic therapy.
D. Asthma exacerbation typically presents with wheezing and difficulty breathing, but it would not typically cause the severe hypotension, confusion, and rapid oxygen desaturation seen in this patient.
Correct Answer is C
Explanation
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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