The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse?

The client's sputum is white colored

The client's arterial blood gas CO2 level is 76 mm hg

The client's pulse oximeter is 90%.

The client has mild SOB when walking to the bathroom

Answer and Explanation

The Correct Answer is B

A. The client's sputum is white colored: White sputum may be normal for a client with COPD and often indicates chronic inflammation without infection. It does not signal an acute or emergent issue that requires immediate intervention.

B. The client's arterial blood gas CO₂ level is 76 mm Hg: A CO₂ level this high indicates significant hypercapnia, which can lead to respiratory acidosis and altered mental status. This finding reflects serious respiratory compromise and requires prompt intervention to prevent respiratory failure.

C. The client's pulse oximeter is 90%: While 90% is on the lower end of acceptable for clients with end-stage COPD, it is often tolerated due to their adapted baseline. It does not represent an immediate threat unless accompanied by other signs of deterioration.

D. The client has mild SOB when walking to the bathroom: Mild shortness of breath with exertion is expected in clients with advanced COPD. It reflects baseline activity tolerance and does not require urgent action unless symptoms worsen.

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Correct Answer is ["B","C","D"]

Explanation

A. Drink juices high in vitamin C: While vitamin C may help support immune function, it does not prevent the transmission of colds to others. This measure is more about personal health and has no direct effect on reducing contagion.

B. Cough into your elbow: Coughing into the elbow instead of the hands prevents the spread of respiratory droplets through touch, reducing the likelihood of contaminating surfaces and infecting others.

C. Wash hands frequently: Hand hygiene is one of the most effective ways to prevent the spread of respiratory viruses. Frequent handwashing helps remove viruses acquired from contaminated surfaces or respiratory secretions.

D. Cover the mouth and nose when sneezing: Covering the mouth and nose with a tissue or elbow during sneezing limits the dispersion of infectious droplets into the air, reducing transmission to others.

E. Use a saline nose spray frequently: Saline sprays may keep nasal passages moist and comfortable, but they do not reduce the risk of spreading infection to others. Their use is symptomatic, not preventive from a contagion standpoint.

A. Bronchitis B. Sinusitis C. Asthma D. Allergic rhinitis

Correct Answer is B

Explanation

A. Bronchitis:Bronchitis presents with a productive cough, chest discomfort, and sometimes wheezing, but it does not usually involve facial tenderness, purulent nasal drainage, or worsening nighttime cough due to postnasal drip. Symptoms also tend to resolve in under 2 weeks.

B. Sinusitis:Sinusitis is characterized by persistent cold-like symptoms lasting more than 10 days, purulent nasal discharge, headache, facial pain or tenderness, and a cough that worsens at night due to postnasal drainage. This description fits the presentation of pediatric sinusitis.

C. Asthma:Asthma presents with wheezing, shortness of breath, and episodic coughing, especially at night or during exertion. It does not cause purulent nasal drainage, facial tenderness, or prolonged cold symptoms, which point more toward sinus infection.

D. Allergic rhinitis:Allergic rhinitis causes sneezing, clear nasal discharge, itchy eyes, and nasal congestion, but not purulent drainage or facial pain. Symptoms are usually triggered by allergens and are not typically accompanied by fever or thick mucus.

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The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

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Explanation

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