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 D

Explanation

A. This response may come across as judgmental or directive, which can be perceived as dismissive of the client's struggle. It does not acknowledge the complexity of the disorder or the client's feelings of helplessness, potentially hindering open communication and trust.
B. While this question encourages exploration of the underlying reasons for the behavior, it might feel probing or intrusive to the client. It could be interpreted as focusing solely on the behavior itself rather than acknowledging the client's recognition of its abnormality or their feelings of helplessness.
C. This response acknowledges and validates the client's awareness of the problem, which can be empowering. It reinforces the client's self-awareness and readiness to address their behavior, promoting a therapeutic alliance based on mutual understanding and respect.
D. This response demonstrates empathy and understanding of the client's feelings. It acknowledges the emotional struggle the client is experiencing and opens the door for further exploration of their feelings and thoughts. It encourages the client to express their emotions and concerns, which is essential in building a supportive therapeutic relationship.

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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