A nurse working in the respiratory unit is caring for a client admitted for end stage COPD. Upon assessment the client's skin is pink, respirations are 13 bpm and saturations are 92% on 6 liters via nasal cannula. The client is complaining of shortness of breath while laying down. What should be the nurse's first priority action?

Retake the vital signs.

Call the health care provider.

Place the client in Fowler's position.

Increase the oxygen rate.

Answer and Explanation

The Correct Answer is C

A) Retake the vital signs:
While taking vital signs is important, the client’s vital signs (respiratory rate of 13 bpm, oxygen saturation of 92%, and normal skin color) suggest that there is no immediate crisis, such as a sudden drop in oxygen saturation or significant hemodynamic instability. Therefore, retaking the vital signs would not address the most urgent issue at the moment, which is the client's shortness of breath while laying down.

B) Call the healthcare provider:
Calling the healthcare provider may eventually be necessary if the patient's condition worsens or remains unrelieved after interventions. However, the first priority should be to manage the client’s immediate symptoms and improve their comfort. The client’s complaint of shortness of breath when lying down suggests that the positioning may be a contributing factor to their discomfort.

C) Place the client in Fowler's position:
The most appropriate first action for a client with end-stage COPD and shortness of breath while lying down is to place the client in Fowler's position. This position (sitting upright, typically at a 45-60° angle) helps to improve lung expansion and reduce the workload of breathing by using gravity to assist in lung ventilation. It also promotes diaphragmatic breathing, which can relieve the feeling of breathlessness.

D) Increase the oxygen rate:
The client is already on 6 liters of oxygen via nasal cannula and has an oxygen saturation of 92%, which is within an acceptable range for a patient with COPD. Increasing the oxygen rate further could risk causing oxygen toxicity or lead to CO2 retention in clients with COPD, as their respiratory drive is often driven by low oxygen levels rather than high carbon dioxide levels. Thus, increasing the oxygen rate should be done cautiously and only if clinically indicated by a healthcare provider.

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Correct Answer is C

Explanation

A) A corticosteroid such as fluticasone:
While corticosteroids, such as fluticasone, are effective for managing chronic asthma and preventing inflammation over time, they are not the first-line treatment during an acute asthma attack. Corticosteroids are typically used for long-term control and maintenance therapy, not for rapid relief of symptoms in an acute exacerbation. Immediate relief is needed in acute situations, which corticosteroids alone do not provide.

B) A long-acting beta 2 agonist such as salmeterol:
Long-acting beta-2 agonists (LABAs), such as salmeterol, are used for maintenance therapy to prevent asthma attacks and should not be used for the immediate treatment of an acute asthma exacerbation. They take longer to start working, and their role is to provide prolonged bronchodilation over time, not to relieve sudden bronchoconstriction.

C) A short-acting beta 2 agonist such as albuterol:
During an acute asthma attack, the immediate goal is to relieve bronchoconstriction and improve airflow. Short-acting beta-2 agonists like albuterol are the first-line treatment because they quickly relax the smooth muscles of the airways, leading to bronchodilation. Albuterol works within minutes, providing rapid relief from the symptoms of wheezing, shortness of breath, and chest tightness.

D) Methylxanthines such as Theophylline:
Methylxanthines (e.g., theophylline) were once used for asthma management but are no longer considered the first-line treatment for acute exacerbations due to their narrow therapeutic range and the potential for toxicity. While theophylline can provide bronchodilation, its onset of action is slower than that of beta-agonists like albuterol, and it is generally reserved for more chronic management of asthma or severe cases where other medications are not effective.

A. Administering oxygen via nasal cannula at 2 U/min B. Helping the client select a low-salt diet C. Maintaining a semi-Fowler's position as often as possible D. Encouraging the client to drink 2 to 3 L of water daily

Correct Answer is D

Explanation

A) Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy may be necessary for clients with COPD, but in this case, the primary concern is thick, tenacious bronchial secretions that the client cannot clear. Administering oxygen may be appropriate if the client has low oxygen saturation, but it does not directly address the difficulty in expectorating sputum. The focus should be on hydration and mobilization of secretions, rather than oxygen administration alone.

B) Helping the client select a low-salt diet:
While a low-salt diet is important for clients with conditions like hypertension or heart failure, it is not directly relevant to the issue of tenacious bronchial secretions in COPD. The priority in this scenario is to improve the client’s ability to clear the thick mucus, which is more effectively addressed by hydration rather than dietary changes.

C) Maintaining a semi-Fowler's position as often as possible:
Positioning the client in a semi-Fowler's position can help improve lung expansion and facilitate breathing. It can also reduce the work of breathing and increase comfort. However, while this is a helpful positioning strategy, it is not the most direct intervention to address the client’s difficulty with expectoration. The client’s difficulty with mucus clearance is best addressed with hydration to thin the secretions.

D) Encouraging the client to drink 2 to 3 L of water daily:
Hydration is one of the most important interventions for clients with COPD who have tenacious bronchial secretions. Adequate fluid intake helps to thin mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of not being able to bring up mucus, making it the most appropriate action to take.

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Correct Answer is C

Explanation

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Explanation

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