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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.
Correct Answer is C
Explanation
A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.