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 D
Explanation
A. Increased sensitivity to cold is not typically associated with Bell's Palsy or ptosis but might be a general sensation change related to nerve involvement.
B. Drooling from the corner of the mouth is a result of facial weakness affecting the muscles responsible for controlling saliva and mouth closure. While drooling is a common symptom of Bell's Palsy due to impaired muscle control, it is not a description of ptosis. Ptosis specifically refers to the drooping of the upper eyelid.
C. Ringing in the ear, or tinnitus, is not a direct symptom of ptosis. Tinnitus might be associated with various conditions affecting the ear or cranial nerves but is not specifically indicative of ptosis, which is related to eyelid drooping.
D. Ptosis refers to the drooping or sagging of the upper eyelid. In the context of Bell's Palsy, this drooping occurs on the affected side due to weakness or paralysis of the muscles that normally help elevate the eyelid.
Correct Answer is C
Explanation
A. Prednisone is a corticosteroid used to reduce inflammation and suppress the immune system. While effective for reducing inflammation and pain, corticosteroids are generally not the first-line treatment for osteoarthritis. They are more commonly used for inflammatory arthritis conditions like rheumatoid arthritis.
B. Etanercept is a biologic agent used to treat autoimmune conditions like rheumatoid arthritis and psoriatic arthritis by targeting tumor necrosis factor-alpha (TNF-alpha) to reduce inflammation. It is not indicated for osteoarthritis, which is a non-inflammatory degenerative joint disease rather than an autoimmune inflammatory disease.
C. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is commonly used to manage pain and inflammation associated with osteoarthritis. NSAIDs like ibuprofen are often the first-line treatment for osteoarthritis because they help reduce pain and inflammation, improve function, and enhance the quality of life for patients. Ibuprofen is a suitable and preferred option for managing symptoms of osteoarthritis.
D. Hydroxychloroquine is an antimalarial drug that is also used to treat autoimmune diseases such as rheumatoid arthritis and lupus. It works by modulating the immune system and reducing inflammation. However, it is not typically used for osteoarthritis, which is not an autoimmune condition.
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