A nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings is most concerning?
The client has a respiratory rate of 22 breaths per minute.
The client has a temperature of 38°C (100.4°F).
The client has a pulse oximetry reading of 88%.
The client has a blood pressure of 140/90 mmHg.
The Correct Answer is C
Choice A rationale
A respiratory rate of 22 breaths per minute is slightly elevated but not necessarily concerning for a client with COPD. COPD patients often have higher respiratory rates due to their chronic lung condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which could be a sign of infection. However, it is not the most concerning finding in a COPD patient.
Choice C rationale
A pulse oximetry reading of 88% is concerning because it indicates hypoxemia. COPD patients often have lower oxygen levels, but a reading below 90% is worrisome and may require supplemental oxygen or other interventions.
Choice D rationale
A blood pressure of 140/90 mmHg is elevated but not immediately concerning in the context of COPD. It is important to monitor, but it is not the most critical finding.
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Correct Answer is A
Explanation
Choice A rationale
Sepsis is a systemic inflammatory response to infection, often characterized by fever (temperature of 38°C or higher) and tachycardia (heart rate of 120 beats per minute or higher). These symptoms indicate the body’s response to a severe infection.
Choice B rationale
Hypovolemic shock is caused by significant fluid loss, leading to decreased blood volume and perfusion. It typically presents with hypotension and tachycardia, but not necessarily fever.
Choice C rationale
Myocardial infarction (heart attack) is characterized by chest pain, shortness of breath, and other symptoms, but fever and tachycardia are not primary indicators.
Choice D rationale
Pulmonary embolism involves a blockage in the pulmonary arteries, leading to symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, but not typically fever.
Correct Answer is A
Explanation
Choice A rationale
Hypersplenism is a condition often associated with cirrhosis, where the spleen becomes overactive. This leads to the destruction of blood cells, causing anemia (low red blood cells), leukopenia (low white blood cells), and thrombocytopenia (low platelets).
Choice B rationale
Peptic ulcer disease primarily affects the stomach and duodenum, leading to ulcers and bleeding. It does not typically cause anemia, leukopenia, and thrombocytopenia in the context of cirrhosis.
Choice C rationale
Cholecystitis is the inflammation of the gallbladder, usually due to gallstones. It does not cause the blood cell abnormalities seen in cirrhosis.
Choice D rationale
Esophageal varices are swollen veins in the esophagus that develop due to portal hypertension in cirrhosis. While they can cause bleeding, they do not directly cause anemia, leukopenia, and thrombocytopenia.