A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing.
Which of the following actions is the nurse’s priority?
Call emergency services for the client.
Increase the oxygen flow to 3 L/min.
Have the client cough and expectorate secretions.
Assess the client’s respiratory status.
The Correct Answer is D
This is the nurse’s priority because it will help determine the severity of the client’s difficulty breathing and guide the appropriate interventions. According to the Mayo Clinic, oxygen therapy for COPD is indicated when there is not enough oxygen in the blood, which can be measured by a pulse oximeter or a blood gas test. Increasing the oxygen flow without assessing the oxygen level could be harmful or ineffective. Having the client cough and expectorate secretions may help clear the airway, but it is not the first action to take. Calling emergency services may be necessary if the client’s condition is life threatening, but it should not be done before assessing the respiratory status.
Choice A is wrong because it does not address the immediate need of assessing the respiratory status and may cause unnecessary panic or delay in treatment.
Choice B is wrong because it does not follow the guidelines for oxygen therapy for COPD, which require a prescription and monitoring of oxygen levels.
Increasing the oxygen flow without assessing the oxygen level could cause oxygen toxicity or suppress the respiratory drive.
Choice C is wrong because it is not the most urgent action to take.
Having the client cough and expectorate secretions may help clear the airway, but it may also increase the work of breathing and worsen hypoxia.
Assessing the respiratory status should come first.
Normal ranges for oxygen saturation are 95% to 100% for healthy individuals and 88% to 92% for most people with COPD. Normal ranges for blood gas tests vary depending on the laboratory, but generally, normal values for arterial blood gas are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, PaO2 80 to 100 mm Hg, HCO3 22 to 26 mEq/L.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
Correct Answer is B
Explanation
According to the National Institute on Aging, health care providers play an important role in recognizing and reporting elder abuse. They have a legal and ethical obligation to report any suspected cases of abuse to the appropriate authorities. Reporting is not voluntary for health care workers.
Choice A is wrong because reporting is not voluntary for health care workers. Choice C is wrong because civil liability cannot result if the abuse can’t be proven. Health care providers are protected by immunity laws when they report suspected abuse in good faith.
Choice D is wrong because evidence of abuse does not need to be collected prior to reporting. Health care providers should report any signs or symptoms of abuse, even if they are not conclusive.
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