1. You are preparing to care for a client with a history of COPD on the med surg floor, who
has been admitted with acute exacerbation of COPD. What findings would you expect
when you assess this client? Select all that apply
A. Decreased 02 saturation on mild exertion.
B. Widened diaphragm on chest radiology.
C. Increased vital capacity during pulmonary function testing.
D. Hypocapnia
E. Hyperinflated lung on chest x-ray.
Rationale :
Clinical manifestations of COPD
➔ Hypoxia
➔ Hypercapnia
➔ Dyspnea on exertion and at rest
➔ Oxygen desaturation with exercise
➔ Use of accessory muscles during respiration
➔ Flattened diaphragm
➔ Decreased vital capacity
This question is based on content. We must have an understanding of COPD and the pathophysiology. The
best strategy here guys is to use the true/ false method when you have select all that apply questions.
A.: Correct /true , due to narrowed airway clearance and inability to exchange oxygen for c02 your client will exhibit
low 02 saturation levels. Clients with COPD usually sat around 85%.
B: Incorrect/ false in a client with COPD the diaphragm will appear flat on x-ray due to accumulated scar tissue and
decreased lung compliance from long standing hyperinflation damage.
C: incorrect / False: We will see a decreased vital capacity due to damage to the lung tissue and diaphragm
D: Incorrect,/false, we know that a client suffering from COPD will have hypercapnia . This occurs because of
narrowing airways and inability to exchange 02 and co2. You may also see ABG results showing respiratory acidosis
because of this.
E: Correct/true , this is a clinical manifestation of COPD. Hyperinflated lungs can be caused by blockages in the air
passages or by air sacs that are less elastic, which interferes with the expulsion of air from the lungs.
, 2. You are suctioning a client via endotracheal tube. During the procedure you note that the
client's heart rate decreases from 78 bpm to 57 bpm. What is the priority nursing action?
A. Ensure that you are only suctioning for 15 seconds
B. Continue to suction and document the client's response
C. Immediatly stop the procedure and reoxingate the client
D. Notify the HCP
Rationale
Priority nursing actions during endotracheal tube suctioning
With priority questions think, if I as the nurse could do only one thing for this client then leave the room,
what would be the most safe, the most important, and provide a positive outcome?
➔ Monitor for : Hypoxemia, cardiac irregularities including decreased heart rate that results from vagal
stimulation, mucosal trauma, paroxysmal coughing, hypotension.
A. Incorrect, you want to suction for only 10 seconds to decrease the risk of vagal stimulation & hypoxemia
Remember to hyperoxygenate your client before suction and in between passes.
B. Incorrect, the client is having vagal reaction , your priority in this case is to stop suction and oxygenate the
client. This is also incorrect because it does nothing for your client to help them get better.
C. Correct, priority in this case is to stop suction and oxygenate the client.
D. Incorrect, this is inappropriate because there are nursing actions you can take before calling the HCP.
Always think what can YOU do before calling backup, this is also considered passing the buck.
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