A nurse is receiving morning report when an alarm notifies the nurse that a client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 89%. The nurse immediately assesses the client, and finds the client resting comfortably in bed on 2 liters of supplemental oxygen via nasal cannula. The client denies distress. Which of the following is the most appropriate nursing action?
Continue to monitor the patient
Silence future alarms
Place the patient on a non-rebreather mask
Increase the oxygen to 4 liters per minute
The Correct Answer is A
A. The client is resting comfortably, denies distress, and has an oxygen saturation of 89% on 2 liters of supplemental oxygen. This is within an acceptable range for many patients with COPD. Given the client's current status, it is appropriate to continue monitoring the oxygen saturation and assess for any changes in condition.
B. While the alarm may be annoying, it is important to keep it active to alert the nurse to any significant changes in the client's oxygen saturation.
C. A non-rebreather mask delivers a higher concentration of oxygen and is typically used in more critical situations. In this case, the client's oxygen saturation is within a safe range, and there is no need to increase the oxygen delivery method.
D. Increasing the oxygen to 4 liters per minute without a clear indication of need could lead to oxygen toxicity, especially in patients with COPD. It is important to titrate oxygen therapy to the lowest level that maintains adequate oxygen saturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
. Shellfish allergies are related to potential reactions to iodinated contrast media used in imaging studies, such as CT scans, rather than to spirometry. Spirometry does not involve contrast media or shellfish, so this question is not pertinent for this test.
B.A Metal implants are typically a concern for imaging tests like MRI, which involve strong magnetic fields. Spirometry, however, does not involve any imaging or use of magnetic fields, so metal implants do not affect spirometry results. Thus, this question is not relevant for spirometry preparation.
C. This is a relevant question for spirometry testing. Bronchodilators are medications used to open the airways and improve breathing. They can affect spirometry results if taken shortly before the test. For accurate assessment, the nurse needs to know if the client has used any bronchodilators, as they might need to adjust the testing protocol or account for the medication's effects on lung function.
D. Spirometry does not typically involve enclosed spaces that would trigger claustrophobia, as it is a breathing test usually performed with the client sitting comfortably in an open space. Claustrophobia is more relevant to imaging studies like MRIs or CT scans, where the client might be in a confined space.
Correct Answer is D
Explanation
A. Hemoglobin levels measure the oxygen-carrying capacity of the blood. A reduced ejection fraction (30%) is more closely related to heart failure or significant cardiac dysfunction, which is not directly indicated by changes in hemoglobin levels.
B. Platelet levels are primarily involved in blood clotting and are less directly related to ejection fraction. Elevated or decreased platelet counts are not typically used as indicators of heart failure severity or reduced ejection fraction.
C. In cases of severe heart failure with a reduced ejection fraction, you may see elevated BUN levels due to these effects. However, it is not directly related to heart failure.
D. BNP is a hormone released by the heart in response to increased pressure and volume overload, typically seen in heart failure. Elevated BNP levels are associated with worsening heart failure and can be elevated in patients with a reduced ejection fraction. In heart failure, especially with an ejection fraction as low as 30%, BNP levels are often significantly elevated.
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