A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?
The client has a respiratory rate of 28 breaths per minute.
The client has a temperature of 38°C (100.4°F).
The client has a blood pressure of 140/90 mmHg.
The client has a heart rate of 90 beats per minute.
The Correct Answer is A
Choice A rationale
A respiratory rate of 28 breaths per minute indicates tachypnea, which is a sign of respiratory distress. Immediate intervention is needed to address the underlying cause and prevent further deterioration of the patient’s condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which may suggest an infection. While this requires medical attention, it is not as immediately critical as respiratory distress.
Choice C rationale
A blood pressure of 140/90 mmHg is considered high, but it does not indicate an immediate need for intervention in the context of COPD. Hypertension should be managed, but it is not an acute emergency.
Choice D rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate an immediate need for intervention. Monitoring the patient’s heart rate is important, but it is not an urgent concern in this scenario.
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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Cerebral ischemia due to an embolus that originates in the left atrium is a common complication of chronic atrial fibrillation (AFib). AFib causes irregular and chaotic electrical signals in the atria, leading to poor blood flow and the formation of blood clots. These clots can travel to the brain, causing a stroke. This is the most acute and severe event associated with chronic AFib.
Choice B rationale
Development of ventricular fibrillation is a life-threatening arrhythmia that can occur in patients with severe heart disease, but it is not a common acute event in chronic AFib. Ventricular fibrillation involves the ventricles and is characterized by rapid, erratic electrical impulses, leading to ineffective heart contractions and sudden cardiac arrest.
Choice C rationale
Ischemia of the cerebellum due to a ruptured intracranial aneurysm is not directly related to chronic AFib. While AFib increases the risk of stroke, it does not specifically cause aneurysms or cerebellar ischemia. Aneurysms are typically related to other risk factors such as hypertension and vascular abnormalities.
Choice D rationale
Prolonged capillary refill secondary to a complete lack of cardiac output is a sign of severe cardiac dysfunction or shock. While AFib can lead to heart failure and reduced cardiac output, it does not typically cause a complete lack of cardiac output. The most acute event related to AFib is the formation of emboli and subsequent stroke.
Correct Answer is C
Explanation
Choice A rationale
Wearing an N95 mask is appropriate for airborne precautions, such as tuberculosis, but not specifically for MRSA, which requires contact precautions.
Choice B rationale
Wearing a facemask is suitable for droplet precautions, such as influenza, but MRSA is primarily spread through direct contact, not droplets.
Choice C rationale
Using a separate disposable blood pressure cuff for patients with draining wounds helps prevent the spread of MRSA. MRSA can be transmitted via contaminated medical equipment.
Choice D rationale
Strict hand washing measures are essential but should be performed more frequently than once every 8-hour shift. Hand hygiene should be practiced before and after patient contact.