The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

Decreased lung sounds on expiration

Respirations are 40 breaths/minute

Anterior-posterior diameter ratio is 1:1

Hyperresonance is noted to percussion

Decreased tactile fremitus is present

Answer and Explanation

The Correct Answer is B

A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.

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Correct Answer is A

Explanation

A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.

A. Provides care that is based on meanings generated by predetermined criteria. B. Provides care that is based on the priorities of the hospital unit workflow. C. Provides care that is the same as the values of the professional health care system. D. Provides care that makes the nurse the leader in determining what is needed. E. Provides care that honors the client's differences and perspectives.

Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may not be responsive to the unique cultural needs of each client.
B. Focusing solely on hospital unit workflow prioritizes efficiency over individualized patient care, which may not respect cultural differences.
C. This approach fails to acknowledge the diverse values and beliefs of clients, which can lead to miscommunication and unmet needs.
D. This implies a top-down approach to care, which may disregard the client’s preferences and cultural context.
E. Honoring the client's differences and perspectives demonstrates the nurse's commitment to culturally responsive care, ensuring that care is tailored to meet the unique needs of each client.

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The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

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Naxlex Comprehensive Predictor Exams

A client with pneumonia is admitted to the medical/surgical floor. Which activity is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally responsive care?

Correct Answer is E

Explanation

The nurse is caring for a client admitted with pneumonia. The patient has a history of smoking 10 cigarettes per day for 30 years. What is the pack year amount? Use numbers only in your answer. No letters.

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