A nurse is monitoring a client with COPD that suddenly becomes restless and anxious. Which of the following steps should the nurse take next?

Assess the client's potassium level.

Check the client's temperature.

Increase the client's oxygen flow rate to 15 L/min.

Encourage the client to perform pursed-lip breathing.

Answer and Explanation

The Correct Answer is D

A) Assess the client's potassium level:
While electrolyte imbalances, including low potassium, can contribute to symptoms like restlessness or muscle weakness, it is not the first priority in a client with COPD who suddenly becomes restless and anxious. Restlessness and anxiety in this context are more likely to be due to hypoxia (low oxygen levels), hypercapnia (high carbon dioxide levels), or respiratory distress.

B) Check the client's temperature:
An elevated temperature may indicate an infection, such as pneumonia or a respiratory tract infection, which can exacerbate COPD symptoms. However, in the context of sudden restlessness and anxiety, this is less likely to be the most immediate cause. The primary concern should be addressing the potential respiratory issues, such as hypoxia or acute exacerbation, rather than focusing on fever, unless other signs of infection are present.

C) Increase the client's oxygen flow rate to 15 L/min:
While it is important to ensure adequate oxygenation in a client with COPD, increasing the oxygen flow rate to 15 L/min may not be appropriate, as COPD patients are typically at risk for oxygen-induced hypercapnia. These patients often rely on low levels of oxygen to stimulate breathing, and administering high-flow oxygen can suppress their respiratory drive, potentially worsening carbon dioxide retention.

D) Encourage the client to perform pursed-lip breathing:
Pursed-lip breathing is a highly effective technique for COPD patients to help increase oxygenation and decrease the work of breathing. This technique involves the client breathing in through the nose and exhaling slowly through pursed lips, which helps to keep the airways open longer and facilitates the removal of trapped air in the lungs.

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Correct Answer is B

Explanation

A) Continue to monitor as this is a normal response to the medication: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not normal responses to the edrophonium test and suggest a cholinergic crisis rather than a simple reaction to the medication. A cholinergic crisis occurs when there is overmedication with cholinergic drugs, leading to excessive stimulation of the parasympathetic nervous system. While mild effects like slight nausea or dizziness can occur, cramping, diaphoresis, and increased oral secretions indicate toxicity, requiring immediate intervention.

B) Administration of atropine: The symptoms the patient is exhibiting—cramping, diaphoresis, and increased oral secretions—are indicative of cholinergic toxicity. Edrophonium, a cholinesterase inhibitor, is used in the Tensilon test to diagnose myasthenia gravis by temporarily improving muscle strength. However, in some cases, the patient may experience a cholinergic crisis from an overdose of the medication, resulting in excess acetylcholine at synapses, which overstimulates the parasympathetic nervous system. Atropine, an anticholinergic agent, blocks the effects of acetylcholine and is used to reverse these symptoms by reducing the excessive parasympathetic activity (e.g., reducing secretions and improving heart rate).

C) Place the patient in the Trendelenburg position: The Trendelenburg position (head down, feet up) is often used in cases of shock to help increase venous return to the heart. However, it is not appropriate for a cholinergic crisis. The patient’s symptoms are not due to hypotension or shock but are related to an overdose of edrophonium causing parasympathetic overstimulation.

D) Administer diphenhydramine (Benadryl) for the allergic reaction: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not related to an allergic reaction. Diphenhydramine (Benadryl) is an antihistamine used for allergic reactions, such as urticaria or anaphylaxis, but it does not treat cholinergic toxicity.

A. Go to the emergency department B. Continue to use salmeterol and fluticasone as prescribed C. Administer an additional rescue dose of Albuterol D. Call the physician

Correct Answer is C

Explanation

A) Go to the emergency department:
An immediate trip to the emergency department is generally not required for a peak expiratory flow rate (PEFR) of 82%. The PEFR of 82% indicates that the client’s airflow is reduced, but it is not necessarily an emergency. PEFR readings are typically classified into zones: green (80-100% of personal best), yellow (50-79% of personal best), and red (below 50% of personal best). A reading of 82% is in the yellow zone, which suggests that the client is experiencing some degree of airway obstruction or worsening asthma symptoms

B) Continue to use salmeterol and fluticasone as prescribed:
While salmeterol (a long-acting beta agonist) and fluticasone (a corticosteroid) are important for long-term asthma control, continuing their use without additional intervention is not the most appropriate action when the PEFR is 82%. A PEFR of 82% indicates that the client’s asthma is not well controlled at the moment, and the nurse should recommend additional short-acting relief to help open the airways (e.g., a rescue inhaler like albuterol.

C) Administer an additional rescue dose of Albuterol:
The correct immediate action is to administer a rescue dose of albuterol. Albuterol is a short-acting beta-agonist that helps open the airways quickly during an asthma exacerbation. A PEFR of 82% falls in the yellow zone, suggesting some obstruction but not an emergency situation. In this case, administering an additional rescue dose of albuterol can help improve airflow and bring the PEFR closer to normal.

D) Call the physician:
While it may be necessary to call the physician if the client’s asthma symptoms do not improve after using a rescue inhaler or if there is a significant decline in symptoms, the first immediate action should be to use a rescue medication like albuterol. Calling the physician may be appropriate after assessing the response to the rescue medication, but it is not the first step in managing a PEFR of 82%.

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A nurse is monitoring a client with COPD that suddenly becomes restless and anxious. Which of the following steps should the nurse take next?

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Correct Answer is B

Explanation

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