A nurse in the med-surgical ICU is evaluating a patient with a diagnosis of chronic copd. The patient is receiving oxygen at a flow rate of 10 L/min via facemask. Which finding would concern the nurse to act immediately?

Respiratory rate of 8 bpm

A large barrel chest

Fine crackles

The patient assumes the orthopenic position

Answer and Explanation

The Correct Answer is A

A) Respiratory rate of 8 bpm:
This a sign of respiratory depression, which can occur in patients with chronic obstructive pulmonary disease (COPD) who are receiving high-flow oxygen. In COPD patients, particularly those with chronic hypercapnia (elevated carbon dioxide), the body may become less sensitive to CO2 buildup and more reliant on low oxygen levels to trigger the respiratory drive. If oxygen is administered at high flow rate, it can reduce the stimulus for breathing, leading to hypoventilation or even respiratory arrest.

B) A large barrel chest:
A barrel chest is a common physical finding in patients with chronic COPD due to the hyperinflation of the lungs. This is a result of air trapping, which is a hallmark of COPD. While it indicates the long-term effects of COPD, it does not require immediate intervention. It is a chronic sign and not an acute or urgent concern unless accompanied by other signs of acute respiratory distress.

C) Fine crackles:
Fine crackles (or rales) on auscultation can be indicative of fluid in the lungs and may suggest conditions such as pulmonary edema, heart failure, or pneumonia. While crackles could be concerning, they are not as immediately life-threatening as a respiratory rate of 8 bpm. In a patient with COPD, crackles might indicate worsening of their condition, possibly due to an infection or fluid overload, but the priority would still be to assess the patient's breathing and ventilation status first.

D) The patient assumes the orthopneic position:
The orthopneic position (sitting upright or leaning forward) is a common way for patients with COPD to relieve shortness of breath. It is a compensatory action to help improve lung expansion and facilitate breathing. While it is a sign of respiratory distress, it is not an immediate emergency. Many COPD patients use this position to cope with chronic difficulty breathing.

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Correct Answer is C

Explanation

A) Take the medication with meals:
Inhaled beclomethasone is a corticosteroid, and it is generally not necessary to take it with meals. Oral corticosteroids are sometimes taken with meals to minimize gastric irritation, but this does not apply to inhaled corticosteroids like beclomethasone. The primary concern with inhaled corticosteroids is not related to meal timing but to oral hygiene to prevent side effects like oral thrush.

B) Limit caffeine intake:
There is no direct contraindication or requirement to limit caffeine intake when taking inhaled beclomethasone. While caffeine can have mild bronchodilatory effects, it does not interfere with the action of beclomethasone or exacerbate asthma symptoms. This is not a priority teaching point for the patient.

C) Rinse the mouth after administration:
One of the most important teaching points when using inhaled beclomethasone is to rinse the mouth after each use. This helps to prevent oral thrush (a fungal infection caused by Candida), which is a common side effect of inhaled corticosteroids. Rinsing the mouth with water after administration helps to remove any leftover medication and reduce the risk of infection, making this the most important instruction.

D) Check the pulse before and after medication administration:
While checking the pulse is important for some medications, such as bronchodilators like albuterol, it is not necessary for inhaled beclomethasone. Beclomethasone is a corticosteroid that primarily works by reducing inflammation in the airways, and it does not have a significant impact on heart rate. Therefore, it is not required to monitor pulse before and after its use.

A. Cyanosis B. Hypotension C. Bradycardia D. Tachycardia

Correct Answer is D

Explanation

A) Cyanosis:
Cyanosis, which is a bluish discoloration of the skin and mucous membranes, typically occurs with severe hypoxia or oxygen deprivation, usually when oxygen saturation levels drop below 85%. Cyanosis is a late sign of hypoxia, not an early sign. In the early stages of hypoxia, the body attempts to compensate, and cyanosis does not typically appear until oxygen levels are significantly low.

B) Hypotension:
While hypotension can be a consequence of severe or prolonged hypoxia, it is generally a late sign. In the early stages of hypoxia, the body compensates through mechanisms such as tachycardia and vasoconstriction, so hypotension would not be expected at this stage. Hypotension in a hypoxic patient usually signals progression to severe respiratory or circulatory failure.

C) Bradycardia:
Bradycardia (slow heart rate) is not typically associated with early hypoxia. Instead, the body tries to compensate for reduced oxygen levels by increasing heart rate (tachycardia) in the early stages. Bradycardia can occur in more severe stages of hypoxia, particularly if the body begins to struggle with compensating or if the patient progresses to a more critical state. However, it is not an early sign of hypoxia.

D) Tachycardia:
Tachycardia (an elevated heart rate) is an early compensatory mechanism that the body employs when oxygen levels are insufficient. The heart increases its rate to pump more blood (and thus oxygen) to vital organs and tissues. Tachycardia is one of the earliest signs of hypoxia and occurs as the body attempts to compensate for the decreased oxygen levels in the bloodstream.

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A nurse in the med-surgical ICU is evaluating a patient with a diagnosis of chronic copd. The patient is receiving oxygen at a flow rate of 10 L/min via facemask. Which finding would concern the nurse to act immediately?

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