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.

Answer and Explanation

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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Correct Answer is C

Explanation

This is because the cognitive domain of learning involves knowledge and understanding of information. By stating 3 ways to avoid his triggers, the patient demonstrates that he has learned and comprehended the information about prevention of inflammation.

Choice A is wrong because it belongs to the psychomotor domain of learning, which reflects learning behavior achieved through neuromuscular motor activities. Checking blood sugar is a physical skill, not a cognitive one.

Choice B is wrong because it belongs to the affective domain of learning, which characterizes the emotional arena reflected by learners’ beliefs, values and interests.

Discussing feelings about dietary changes is an affective outcome, not a cognitive one.

Choice D is wrong because it also belongs to the psychomotor domain of learning, as it involves demonstrating proper use of inhaler, which is another physical skill.

A. Instruct the client to use pursed-lip breathing. B. Plan to have the client lay down for 1 hr after meals. C. Restrict the client’s fluid intake to less than 1 L/day. D. Encourage the client to use the upper chest for respiration.

Correct Answer is A

Explanation

Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.

Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.

Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.

Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.

It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.

Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.

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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?

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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?