A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress.
Which of the following manifestations should the nurse include?

Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.

Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.

Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.

Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.

Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.

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.