A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding should the nurse expect?

Correct Answer: A

Rationale: The correct answer is A: Increased anterior-posterior (AP) chest diameter. In COPD, the lungs lose their elasticity, trapping air and causing hyperinflation. This leads to increased AP chest diameter due to barrel chest appearance. Option B is incorrect because COPD often results in an increased respiratory rate due to difficulty breathing. Option C is incorrect as weight gain is not a typical finding in COPD, which is often associated with weight loss. Option D is incorrect as a productive cough with yellow sputum is more commonly seen in respiratory infections rather than COPD exacerbations.

Correct Answer: B

Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. In a client with COPD, a respiratory rate of 10 breaths per minute indicates severe respiratory depression and impending respiratory failure. Immediate intervention is necessary to prevent hypoxia and respiratory arrest. Oxygen saturation of 91% (choice A) is low but not as critical as a low respiratory rate. Shortness of breath (choice C) is expected in COPD but does not indicate immediate danger. Use of accessory muscles (choice D) is a sign of respiratory distress, but a low respiratory rate is more concerning for imminent respiratory failure.

Correct Answer: C

Rationale: The correct answer is C: Dullness on percussion. Pneumonia is characterized by consolidation of lung tissue, causing dullness on percussion due to increased density. Fremitus (A) and tactile fremitus (D) are decreased in conditions like pleural effusion or pneumothorax, not pneumonia. Hyperresonance (B) is associated with conditions like emphysema, not pneumonia. In pneumonia, the affected area is consolidated, leading to dullness on percussion.

Correct Answer: A

Rationale: The correct answer is A because the ability to ambulate without dyspnea indicates effective oxygen therapy. When a client can move without experiencing difficulty breathing, it suggests that the oxygen therapy is adequately supporting their oxygenation needs. In contrast, options B, C, and D do not directly indicate the effectiveness of oxygen therapy. Option B (respiratory rate of 24 breaths per minute) may be within normal range but does not confirm the therapy's efficacy. Option C (oxygen saturation of 92%) is below the desired range of 95-100%, indicating inadequate oxygenation. Option D (productive cough) is unrelated to the assessment of oxygen therapy effectiveness.

Correct Answer: C

Rationale: Step-by-step rationale for choice C (Administer oxygen to maintain saturations greater than 94%): 1. Oxygen is crucial in managing asthma exacerbations to improve oxygen saturation levels and prevent hypoxemia. 2. Decreased pulse oxygen saturation indicates hypoxemia, which can lead to serious complications. 3. Maintaining saturations greater than 94% ensures adequate oxygenation of tissues and organs. 4. Administering oxygen promptly can help alleviate respiratory distress and improve the client's condition. Summary of why other choices are incorrect: - Choice A (Administer albuterol inhaler): While albuterol is a common medication for asthma, oxygen therapy is the priority in this scenario to address hypoxemia. - Choice B (Assess for tracheal deviation): Tracheal deviation is not typically associated with asthma exacerbations and is not the most urgent action needed in this situation. - Choice D (Perform peak expiratory flow measurements): Peak expiratory flow