Question

A nurse is caring for a client with COPD that may be experiencing bronchospasm. Which assessment finding would indicate bronchospasm?

Answer 1

Correct Answers:

Wheezes or diminished breath sounds on auscultation

Rationale :

🔹 Bronchospasm causes narrowing of the airways, resulting in wheezing or diminished breath sounds.

🔹 Slow respirations may occur in fatigue but are not indicative of bronchospasm.

🔹 Reduced respiratory rate or lethargy may suggest hypoxia but not specific to bronchospasm.

🔹 Crackles indicate fluid in alveoli, not bronchospasm.

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Answer 2

Correct Answers:

Restlessness anxiety.

Rationale :

🟢 Hypoxia stimulates the sympathetic nervous system, producing early signs like restlessness and anxiety.

🟢 This occurs before cyanosis or lethargy develops, which are late signs of tissue hypoxia.

🟢 Tachycardia and increased respiratory rate may accompany these early manifestations.

🟢 Bradycardia is typically a late sign, often preceding cardiac arrest if hypoxia worsens.

🟢 Recognizing early hypoxia allows nurses to initiate interventions, such as supplemental oxygen, before complications arise.

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Answer 3

Correct Answers:

Wheezing
Tight feeling in chest
Rapid, labored breathing
Tachycardia

Rationale :

🔵 Asthma exacerbation is characterized by airway inflammation, bronchospasm, and mucus plugging.

🔵 Wheezing results from turbulent airflow, often noted during expiration.

🔵 Chest tightness occurs due to airway constriction and increased work of breathing.

🔵 Rapid, labored breathing compensates for airflow limitation and hypoxemia.

🔵 Tachycardia develops from hypoxemia and sympathetic activation.

🔵 Fever is not a typical asthma symptom unless associated with infection.

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Answer 4

Correct Answers:

Leukocytosis.

Rationale :

🔹 Bacterial pneumonia triggers immune activation, increasing WBC count to fight infection.

🔹 Leukocytosis is primarily neutrophilic, reflecting bacterial etiology.

🔹 Erythrocytopenia, eosinophilia, or thrombocytopenia are not associated with acute bacterial infections.

🔹 Monitoring WBC trends helps evaluate response to antibiotics.

🔹 Recognizing leukocytosis early aids in diagnosing severity and guiding interventions.

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Answer 5

Correct Answers:

use of accessory muscles in breathing

Rationale :

🟡 Accessory muscle use indicates increased work of breathing and impending respiratory failure.

🟡 Peak flow 240 L/min may be below personal best, but accessory muscle use signals acute distress.

🟡 Respiratory rate of 26 is mild tachypnea, whereas accessory muscle use shows significant respiratory compromise.

🟡 SpO₂ 91% indicates mild hypoxemia, but observation of physical signs takes priority.

🟡 Early recognition allows timely administration of bronchodilators or oxygen, preventing progression to respiratory arrest.

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Answer 6

Correct Answers:

Withhold food and liquids until the client's gag reflex returns.

Rationale :

🔵 Flexible bronchoscopy uses local anesthesia that may suppress gag reflex, increasing aspiration risk.

🔵 Withholding food and fluids prevents aspiration pneumonia and airway compromise.

🔵 Suctioning or irrigating before gag return can injure mucosa or trigger aspiration.

🔵 Clients may resume talking once reflex returns; 24 hr silence is unnecessary.

🔵 Post-procedure monitoring includes vital signs, oxygenation, and airway patency.

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Answer 7

Correct Answers:

Confusion

Rationale :

🔹 Older adults with pneumonia often present with altered mental status or confusion rather than typical fever/cough.

🔹 Confusion may result from hypoxia, infection, or metabolic changes.

🔹 Hypertension, tympany on percussion, and unequal pupils are not typical manifestations.

🔹 Early recognition of confusion leads to prompt treatment and reduced complications.

🔹 Monitoring neurologic status in older adults is critical for timely intervention.

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Answer 8

Correct Answers:

"Eat six small meals a day high in protein and low in carbohydrates."

Rationale :

🟢 COPD increases energy expenditure due to labored breathing; small frequent meals prevent early satiety.

🟢 High protein preserves muscle mass, and low carbohydrates reduce CO₂ production, improving ventilation.

🟢 Large meals or high-carb intake exacerbate dyspnea.

🟢 Adequate caloric intake maintains nutritional status and prevents weight loss.

🟢 Small, frequent meals enhance oxygenation and recovery.

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Answer 9

Correct Answers:

Respiratory acidosis

Rationale :

🔵 ABG: pH 7.29 (acidotic), PaCO₂ 56 mmHg (high), HCO₃ 24 (normal) → respiratory acidosis.

🔵 High CO₂ reflects alveolar hypoventilation due to COPD.

🔵 PaO₂ 70 mmHg indicates mild hypoxemia.

🔵 Respiratory acidosis occurs from CO₂ retention, causing pH drop.

🔵 Chronic compensation may occur via renal bicarbonate retention, but acute presentation is acidotic.

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Answer 10

Correct Answers:

Wheezes

Rationale :

🟡 Continuous high-pitched musical sounds on exhalation indicate narrowed bronchi/airway obstruction.

🟡 Rhonchi are low-pitched, often cleared with coughing; stridor is inspiratory and upper airway.

🟡 Crackles indicate alveolar fluid, not airway constriction.

🟡 Wheezing is characteristic of asthma or COPD exacerbation.

🟡 Documenting wheezes helps monitor disease progression and therapy effectiveness.

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RN 324 Quiz 2 Medical surgical

No.

1 :
A nurse is caring for a client with COPD that may be experiencing bronchospasm. Which assessment finding would indicate bronchospasm?

2 :
A nurse is assessing a client for hypoxia secondary to their emphysema (COPD). Which clinical manifestation should nurse to observe in the client with hypoxia?

3 :
Which findings are expected during an asthma exacerbation? Select all that apply.

4 :
A client is diagnosed with bacterial pneumonia. Which clinical manifestation should the nurse expect?

5 :
A nurse assesses a client with a history of asthma. Which finding indicates the client is in distress requiring the ruse to take Elim?

6 :
A nurse is caring for a client that just had a flexible bronchoscopy Which of the following nursing actions is appropriate?

7 :
A nurse in an emergency department is assessing an older adult client with community-acquired pneumonia. Which of the following findings should the nurse expect?

8 :
A client with chronic obstructive pulmonary disease (COPD) states to the nurse realize proper nutrition is important but I have no appetite. Which nursing response is most helpful'

9 :
A client with chronic obstructive pulmonary disease (COPD) presents to the emergency department and arterial blood gases are drawn. The results are Ph 7.29, PaCO2, 56 mmHg, PaO2 70 mmHg and HCO3 24. How should the nurse interpret these results?

10 :
When a client with asthma exhales. the nurse auscultates continuous high-pitched musical squeaking sounds. How should the nurse document this finding?

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RN 324 Quiz 2 Medical surgical

No.

1 : A nurse is caring for a client with COPD that may be experiencing bronchospasm. Which assessment finding would indicate bronchospasm?

2 : A nurse is assessing a client for hypoxia secondary to their emphysema (COPD). Which clinical manifestation should nurse to observe in the client with hypoxia?

3 : Which findings are expected during an asthma exacerbation? Select all that apply.

4 : A client is diagnosed with bacterial pneumonia. Which clinical manifestation should the nurse expect?

5 : A nurse assesses a client with a history of asthma. Which finding indicates the client is in distress requiring the ruse to take Elim?

6 : A nurse is caring for a client that just had a flexible bronchoscopy Which of the following nursing actions is appropriate?

7 : A nurse in an emergency department is assessing an older adult client with community-acquired pneumonia. Which of the following findings should the nurse expect?

8 : A client with chronic obstructive pulmonary disease (COPD) states to the nurse realize proper nutrition is important but I have no appetite. Which nursing response is most helpful'

9 : A client with chronic obstructive pulmonary disease (COPD) presents to the emergency department and arterial blood gases are drawn. The results are Ph 7.29, PaCO2, 56 mmHg, PaO2 70 mmHg and HCO3 24. How should the nurse interpret these results?

10 : When a client with asthma exhales. the nurse auscultates continuous high-pitched musical squeaking sounds. How should the nurse document this finding?

1 :
A nurse is caring for a client with COPD that may be experiencing bronchospasm. Which assessment finding would indicate bronchospasm?

2 :
A nurse is assessing a client for hypoxia secondary to their emphysema (COPD). Which clinical manifestation should nurse to observe in the client with hypoxia?

3 :
Which findings are expected during an asthma exacerbation? Select all that apply.

4 :
A client is diagnosed with bacterial pneumonia. Which clinical manifestation should the nurse expect?

5 :
A nurse assesses a client with a history of asthma. Which finding indicates the client is in distress requiring the ruse to take Elim?

6 :
A nurse is caring for a client that just had a flexible bronchoscopy Which of the following nursing actions is appropriate?

7 :
A nurse in an emergency department is assessing an older adult client with community-acquired pneumonia. Which of the following findings should the nurse expect?

8 :
A client with chronic obstructive pulmonary disease (COPD) states to the nurse realize proper nutrition is important but I have no appetite. Which nursing response is most helpful'

9 :
A client with chronic obstructive pulmonary disease (COPD) presents to the emergency department and arterial blood gases are drawn. The results are Ph 7.29, PaCO2, 56 mmHg, PaO2 70 mmHg and HCO3 24. How should the nurse interpret these results?

10 :
When a client with asthma exhales. the nurse auscultates continuous high-pitched musical squeaking sounds. How should the nurse document this finding?