01. Answer: c. Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.
02. Answer: a. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump into pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.
03. Answer: a. The client’s problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Activity intolerance is a likely diagnosis but is not related to the client’s nutritional problems. Weight loss is not a nursing diagnosis. Ineffective breathing pattern may be a problem, but this diagnosis does not specifically address the problem of weight loss described by the client.
04. Answer: a. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection are not consistent with a diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.
05. Answer: d. A client recovering from an URI should report decreasing or no nasal discharge and obstruction. Daily fluid intake should be increase to more than 1 L every 24 hours to liquefy secretions. The temperature should be below 100*F (37.8*C) with no chills or diaphoresis. A productive cough with chest pain indicated pulmonary infection, not an URI.
06. Answer: b. As the severe asthma attack worsens, the client becomes fatigued and alveolar hypotension develops. This leads to carbon dioxide retention and hypoxemia. The client develops respiratory acidosis. Therefore, the PaCO2 level increase, the PaO2 level decreases, and the pH decreases, indicating acidosis.
07. Answer: a. Irregular heart rates should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on the beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, petal edema, or bradycardia.
08. Answer: b. The pH (7.50) reflects alkalosis, and the low PaCO2 indicated the lungs are involved. The client should immediately be placed on oxygen via mask so that the SaO2 is brought up to 95%. Encourage slow, regular breathing to decrease the amount of CO2 she is losing. This client may have pulmonary embolism, so she should be monitored for this condition (4), but it is not the first intervention. Sodium bicarbonate (3) would be given to reverse acidosis; mechanical ventilation (1) may be ordered for acute respiratory acidosis.
09. Answer: a. Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood.
10. Answer: b. Chronic hypoxia associated with COPD may stimulate excessive RBC production (polycythemia). This results in increased blood viscosity and the risk of thrombosis. The other nursing diagnoses are not applicable in this situation.
Refrence
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