A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air.
The patient’s pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse’s priority action?
Auscultate the lung fields to identify any abnormal sounds.
Administer oxygen via a nasal cannula at 8 liters per minute.
Elevate the head of the patient’s bed to an upright position.
Assist the patient to get up to the chair.
The Correct Answer is B
Choice A rationale
While auscultating the lung fields can provide valuable information about the patient’s respiratory status, it is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.
Choice B rationale
Administering oxygen is the most appropriate action for a COPD patient with an oxygen saturation of 89%. This will help increase the patient’s oxygen saturation and alleviate their shortness of breath.
Choice C rationale
Elevating the head of the bed can help improve lung expansion and ease breathing, but it is not as immediately effective as administering oxygen.
Choice D rationale
Assisting the patient to get up to the chair is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
During systole, the ventricles contract to pump blood out of the heart to the body and lungs.
Choice B rationale
The ventricles relax during diastole, not systole.
Choice C rationale
The atria also contract during systole, but this occurs just before ventricular systole.
Choice D rationale
This choice is incorrect because both the ventricles and the atria contract during systole.
Correct Answer is A
Explanation
Choice A rationale
The Quality and Safety Education for Nurses (QSEN) project provides a roadmap to transform nursing by integrating six competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
Choice B rationale
The Institute of Medicine (IOM) is a non-profit organization that provides unbiased and authoritative advice to decision makers and the public. While the IOM has made significant contributions to health care, it does not specifically develop safety competencies for nurses.
Choice C rationale
The Centers for Disease Control (CDC) is a national public health institute in the United States. It conducts and supports health promotion, prevention and preparedness activities in the United States, with the goal of improving overall public health.
Choice D rationale
The Health Insurance Portability and Accountability Act (HIPAA) is legislation that provides data privacy and security provisions for safeguarding medical information. While HIPAA contributes to the safety and privacy of patient information, it does not develop safety competencies for nurses.
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