The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?
Decreased lung sounds on expiration
Respirations are 40 breaths/minute
Anterior-posterior diameter ratio is 1:1
Hyperresonance is noted to percussion
Decreased tactile fremitus is present
The Correct Answer is B
A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.
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Correct Answer is E
Explanation
A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.
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.