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The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?
- A. Use of accessory muscles
- B. Oxygen saturation of 94%
- C. Carbon dioxide level of 45 mmHg
- D. Respiratory rate of 20 breaths per minute
Correct Answer: C
Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.
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A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?
- A. Temperature of 101.5°F
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 90/60 mmHg
Correct Answer: D
Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.
A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?
- A. Confusion and altered mental status
- B. Increased abdominal girth
- C. Yellowing of the skin
- D. Peripheral edema
Correct Answer: A
Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.
A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?
- A. Increase the oxygen flow rate to 4 liters per minute.
- B. Instruct the client to rest until the oxygen saturation improves.
- C. Discontinue ambulation and return the client to bed.
- D. Encourage the client to breathe more deeply.
Correct Answer: C
Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.
During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
- A. Notify the pediatrician immediately.
- B. Teach the parents about congenital heart defects.
- C. Document the finding in the infant's record.
- D. Apply oxygen via nasal cannula at 3 L/min.
Correct Answer: C
Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Inspiratory crackles
Correct Answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.