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

Giving a report to a provider in SBAR format is not related to one of the National Patient Safety Goals (NPSGs). The NPSGs are a set of standards developed by The Joint Commission to improve patient safety andquality of care. They address specific areas of concern such as infection prevention, medication safety, patient identification, communication, and alarm management.

Choice A is wrong because refraining from changing alarm settings is related to NPSG 06.01.01, which aims to improve the safety of clinical alarm systems. Choice B is wrong because using 2 patient identifiers for medication administration is related to NPSG 01.01.01, which aims to improve the accuracy of patient identification.

Choice D is wrong because arriving 15 minutes prior to the start of the shift is related to NPSG 02.03.01, which aims to improve the effectiveness of communication among caregivers.

A. An influenza vaccine. B. A broad-spectrum antibiotic. C. A bronchodilator. D. A corticosteroid.

Correct Answer is A

Explanation

This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.

Choice B. A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.

Choice C. A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.

Choice D. A corticosteroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.

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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?