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?

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.