A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Encourage the client to take breaks from oxygen use to prevent tolerance.

Maintain nasal oxygen at a 1 to 2 liter/minute flow rate.

Assess cheeks and posterior ears for signs of skin breakdown.

Teach the client how to safely increase oxygen flow when they deem necessary.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While it is important to monitor oxygen use to prevent hypoxia and hypercapnia, taking breaks from oxygen use is not typically recommended for clients with COPD. These clients often require supplemental oxygen to maintain adequate oxygen saturation.
Choice B rationale
Maintaining a low flow rate of oxygen is crucial in clients with COPD. These clients are often “CO2 retainers,” and administering a high concentration of oxygen can suppress their respiratory drive, leading to further CO2 retention and respiratory distress.
Choice C rationale
While it is important to assess for signs of skin breakdown in clients receiving oxygen therapy, this is not the priority when administering nasal oxygen to a client with COPD38.
Choice D rationale
Clients should not adjust their oxygen flow rate without medical supervision. Increasing the oxygen flow rate can lead to hyperoxia, which can be harmful, especially in clients with COPD who are CO2 retainers.

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Correct Answer is D

Explanation

Choice A rationale
This response is more threatening than assertive. Threatening disciplinary action does not address the issue in a constructive manner and may create further conflict.
Choice B rationale
This response is more accusatory than assertive. It may make the colleague defensive and does not encourage open communication.
Choice C rationale
This response is more avoidant than assertive. It does not address the issue directly with the colleague and does not promote effective teamwork.
Choice D rationale
This response is assertive. It communicates the nurse’s feelings and needs clearly and respectfully, without blaming or threatening the colleague. It promotes open communication and effective teamwork.

A. Report the absence of spontaneous respirations. B. Encourage the patient to attempt to breathe on their own. C. Provide passive range-of-motion exercises. D. Respond to ventilator alarms.

Correct Answer is D

Explanation

Choice A rationale
Reporting the absence of spontaneous respirations is important, but it is not the priority action. The patient is on mechanical ventilation, so the absence of spontaneous respirations is expected.
Choice B rationale
Encouraging the patient to attempt to breathe on their own is not the priority action. The patient is receiving mechanical ventilation, which means they are likely unable to breathe adequately on their own.
Choice C rationale
Providing passive range-of-motion exercises is important for overall patient mobility and prevention of complications such as deep vein thrombosis, but it is not the priority action in this case.
Choice D rationale
Responding to ventilator alarms is the priority action. Alarms may indicate a change in the patient’s condition or a problem with the ventilator. Immediate response is necessary to ensure the patient’s safety.

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A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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