Question

A nurse is caring for a client who has COPD. a Exhibit 1 Exhibit 2 Exhibit 3 Nurses' Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. A nurse is caring for a client who has COPD. Exhibit 1 Exhibit 2 Exhibit 3 Vital Signs 1000: Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 99/min Respirations 32/min Oxygen saturation 85% on room air A nurse is caring for a client who has COPD. а Day Exhibit 3 Exhibit 1 Exhibit 2 Diagnostic Results 1200: Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. Select the 3 findings that require follow-up. . Breath sounds Blood pressure Oxygen saturation Temperature Heart rate
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Answer 1

the right choice is A), C), D) are the 3 condition that require followup by the nurse.

Vital indicators of the COPD patient:

Temperature is 38.6° C, which is higher than the patient's usual body temperature of 37° C.

thus monitoring and follow-up should be used.

Blood pressure: 114/56 mm Hg — Since an adult's typical blood pressure ranges from 90 to 119 systolic over 60 to 79 diastolic, the diastolic reading is slightly lower in this case.

Heart rate: 99 beats per minute; typical range is 60 to 100 beats per minute, so patient's heart rate is normal.

respiration rate: 32/min, when the average respiratory rate is 12–16/min.

Therefore, the patient's respiration rate has greatly increased. Follow up and monitoring are required.

85% oxygen saturation compared to a normal range of 95-100%

It has fallen significantly, therefore it needs to be monitored and followed up on frequently.

Thus the right choice is A), C), D) are the 3 condition that require follow up by the nurse.

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