a nurse cares for a client with chronic obstructive pulmonary disease copd who is receiving oxygen therapy which assessment finding requires the nurse
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?

Correct answer: D

Rationale: A decrease in the client's respiratory rate to 10 breaths per minute, while receiving oxygen therapy for COPD, is a concerning finding that may indicate carbon dioxide retention and respiratory depression. This situation requires immediate action to prevent further complications. An oxygen saturation of 90% is within an acceptable range for COPD patients on oxygen therapy. A respiratory rate of 22 breaths per minute and reports of shortness of breath are common in clients with COPD and may not necessitate immediate action unless accompanied by other concerning symptoms.

2. When teaching a client with chronic obstructive pulmonary disease who will start using fluticasone via MDI twice daily, which instruction should the nurse include?

Correct answer: B

Rationale: It is crucial for clients using inhaled corticosteroids like fluticasone to inspect their mouths daily for signs of oral thrush, a common side effect. Checking the mouth can help identify lesions early, allowing for timely intervention to prevent worsening of the condition. Monitoring heart rate is not specifically required for this medication. Fluticasone is a maintenance medication used to manage COPD, not to relieve acute attacks. Skipping doses, especially in the morning, can lead to inadequate control of COPD symptoms.

3. A client with diabetes is experiencing symptoms of hypoglycemia. What should the nurse administer first?

Correct answer: D

Rationale: The correct first intervention for a client experiencing hypoglycemia is administering 15-20 grams of fast-acting carbohydrate orally. If the client is conscious and able to swallow, providing quick-acting carbohydrates helps raise blood glucose levels rapidly and effectively. This approach is preferred over other options like administering insulin, dextrose solution intravenously, or glucagon, which are not the initial interventions for hypoglycemia.

4. A healthcare professional is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?

Correct answer: B

Rationale: Absent breath sounds may indicate a pneumothorax, a serious complication post lung biopsy. This condition requires immediate attention to prevent respiratory distress.

5. A client with COPD is developing a plan of care. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: In COPD, pursed-lip breathing helps improve breathing efficiency by maintaining positive pressure in the airways, preventing airway collapse, and promoting oxygenation. This technique assists in controlling respiratory rate, reducing dyspnea, and enhancing oxygen saturation levels. Restricting fluid intake is not typically a part of COPD management. Providing a low-protein diet is not a standard intervention for COPD. Early-morning hours are generally not recommended for exercise due to cooler temperatures and higher pollution levels, which can exacerbate COPD symptoms.

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