Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

barrel chest

respiratory rate of 22 per minute

Oral cyanosis

decreased lung sounds on expiration

Pursed-lip expiration

Answer and Explanation

The Correct Answer is C

A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.

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Correct Answer is ["A","D"]

Explanation

A. Asking about shortness of breath is critical subjective data that indicates respiratory distress.
B. Palpating for masses is more of a physical assessment and does not yield subjective data.
C. Inspecting skin and nails is also part of the objective assessment rather than subjective data.
D. Inquiring about the color and quantity of sputum provides important subjective data related to respiratory function.
E. Auscultation is an objective assessment technique and does not pertain to subjective data.

A. The client is currently febrile with an oral temperature of 101.2°F B. The client is mildly anxious about their condition. C. The client is reporting feeling nauseated D. The client's pain rated 8 out of 10 on a numerical scale E. The client is asking questions about their health status.

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

Explanation

A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.
B. Mild anxiety may not require postponement, as it can be addressed during teaching.
C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.
D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.
E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.

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Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

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Naxlex Comprehensive Predictor Exams

What subjective data should the nurse obtain about a client's respiratory status? Select all that apply.

Correct Answer is ["A","D"]

Explanation

A nurse is preparing to teach clients. Which client finding will cause the nurse to postpone a teaching session? (Select all that apply)

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

Explanation

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Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

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