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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Lint-free pipe cleaner:A lint-free pipe cleaner is ideal for drying the inner cannula because it won’t introduce fibers or debris into the airway. It ensures that the cannula is thoroughly dried without increasing the risk of aspiration or airway irritation from lint.
B. The inner cannula does not need to be dried before reinserting it into the outer cannula:Moisture left inside the cannula can promote bacterial growth and lead to infection. Drying the cannula is an essential step to prevent microbial contamination and to maintain patency and safety.
C. Q-tip:Q-tips can shed fibers and are not suitable for internal tracheostomy components. Using them may lead to lint being introduced into the airway, increasing the risk of irritation or infection.
D. Medical air:Medical air is not used to dry tracheostomy components. It is not practical, and it may not fully dry narrow internal surfaces. Manual drying with a lint-free material is safer and more effective.
Correct Answer is D
Explanation
A. When the chest x-ray shows no indication of TB:Chest x-rays can remain abnormal even after successful treatment. Radiographic improvement is not a reliable indicator for stopping therapy.
B. When the TB skin test is no longer positive:The TB skin test often remains positive for life after infection or exposure and does not reflect current disease activity or treatment response.
C. When the medication has been taken for 6 months:Although the standard treatment duration is often 6 months, therapy duration alone is not sufficient without confirming bacteriological clearance via sputum testing.
D. When three consecutive sputum cultures are negative:This is the most reliable indicator that the patient is no longer infectious and the treatment has been effective, especially in active pulmonary TB. It ensures eradication of Mycobacterium tuberculosis.
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