A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?

Speaks in short phrases

Increased sputum production

Use of accessory muscles to breathe

Pulse oximetry reading of 90%

Answer and Explanation

The Correct Answer is C

A.   Speaking in short phrases can indicate increased effort or difficulty in breathing. While it suggests respiratory compromise, it is not an immediate concern unless it worsens or is accompanied by other severe symptoms.
B.   Increased sputum production is common in clients with COPD and can indicate exacerbation or infection. It should be monitored closely but may not require immediate reporting unless it is severe or associated with other concerning symptoms.
C.   This finding indicates increased respiratory effort and potential respiratory distress, which requires prompt attention and intervention.
D.   A pulse oximetry reading of 90% indicates that the client's oxygen saturation is below the normal range but acceptable in client with COPD due to chronic hypoxemia.

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Correct Answer is C

Explanation

A. The toe could also be affected by the edema leading to inaccurate reading.
B. Placing the pulse oximeter probe on a skin fold is not recommended. Skin folds can obscure proper positioning of the probe and interfere with accurate readings. Additionally, skin folds may not adequately represent blood flow and oxygenation levels compared to other sites.
C. This location is recommended because it is usually free of the issues that can affect the extremities, such as poor circulation or changes in peripheral perfusion, and can provide a more reliable saturation reading.
D. The finger is the most common site for applying a pulse oximeter probe due to its accessibility and reliability. However, in cases where the fingers are not suitable, such as when there is significant edema or thickened toenails, alternative sites like the toe may be preferred.

A. Agitation B. Nausea C. Dysphagia D. Warm, dry skin

Correct Answer is A

Explanation

A. Agitation can be a manifestation of hypoxia. As the body senses inadequate oxygen supply, it may respond with restlessness or agitation as a compensatory mechanism to increase oxygen intake.
B. Nausea is not a typical finding in hypoxia.
C. Dysphagia refers to difficulty swallowing and is not typically associated with hypoxia. It is more commonly related to neurological or structural issues affecting the swallowing mechanism.
D. Warm, dry skin is not a typical manifestation of hypoxia. In fact, hypoxia often results in cool, clammy, or cyanotic (bluish) skin due to inadequate oxygen perfusion.

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A nurse is providing care to a client who has COPD and is receiving supplemental oxygen. Which of the following findings should the nurse report to the RN immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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