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. 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.
Correct Answer is C
Explanation
A. Clamping the chest tube near the water seal is not recommended because it can lead to complications such as a tension pneumothorax. The chest tube should remain unclamped unless instructed by the healthcare provider.
B. Repositioning the client may be necessary if the rise in the water seal chamber is due to a physical obstruction or positioning issue. However, this is not the first action to take.
C. A rise in the water seal chamber with inspiration (tidal fluctuation) is a normal finding in a chest tube system. It indicates that the lung is re-expanding and that the pleural space is still connected to the atmosphere. The nurse should continue to monitor the client and the chest tube system for any other changes.
D. Immediate notification of the provider is not necessary unless there are other signs of complications, such as sudden changes in the drainage amount, a lack of fluctuation, or signs of respiratory distress.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.