The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention?
a. The patient is unable to count out loud past 15 after a deep breath.
b. The patient's nails are noticeably clubbed.
c. The patient's sputum has turned from yellow to greenish-brown.
d. The patient has stridor with wheezes heard in all lung fields.
e. The patient's forced vital capacity has increased from 2.8 to 3.4 L.
f. The patient has become confused and mildly disoriented.
ANS: A, C, D, F
A patient who is unable to count out loud past 15 after a deep breath is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Stridor and wheezes is indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide.
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