A nurse is caring for a client who has been admitted with asthma exacerbation and is experiencing increased wheezing and has an oxygen saturation of 91%. The client is scheduled for his next breathing treatment in 1hr. Which of the following actions should the nurse take?

A. Nausea

While nausea can occur in hypoxia, it is less common compared to other symptoms such as dyspnea (difficulty breathing), confusion, or cyanosis (bluish discoloration of the skin and mucous membranes).

B. Dysphagia

Dysphagia, or difficulty swallowing, is not typically associated with hypoxia. It is more commonly seen in conditions affecting the esophagus or neurological disorders affecting swallowing function.

C. Agitation

Manifestations of hypoxia can vary depending on the severity and duration of oxygen deprivation. Agitation is a common finding in hypoxia, particularly in cases of acute or severe hypoxemia. As the body's oxygen supply becomes compromised, the brain may perceive this as a threat, leading to increased anxiety, restlessness, and agitation as the body attempts to compensate for the lack of oxygen.

D. Warm, dry skin

Warm, dry skin is not a typical finding in hypoxia. Instead, hypoxia may lead to peripheral vasoconstriction and cool, clammy skin as the body attempts to conserve oxygen and maintain core body temperature.

A. Instruct the client to use a pursed-lip breathing technique.

Pursed-lip breathing is a technique commonly used to help relieve dyspnea, particularly in individuals with COPD. This technique involves breathing in through the nose and exhaling slowly through pursed lips, which helps to prolong exhalation, reduce airway collapse, and improve oxygen exchange. While pursed-lip breathing can be beneficial, it should not be the priority action when the client reports difficulty breathing. Before initiating any breathing techniques, the nurse should first assess the client's respiratory status to determine the severity of the breathing difficulty and whether additional interventions are necessary.

B. Evaluate the client's respiratory status.

This is the correct priority action in this scenario. When a client with COPD reports difficulty breathing, the nurse's first step should be to thoroughly assess the client's respiratory status. This assessment involves evaluating respiratory rate, depth, effort, oxygen saturation levels, auscultating lung sounds, and assessing for signs of respiratory distress. By conducting a comprehensive assessment, the nurse can determine the severity of the client's symptoms, identify any potential exacerbating factors or complications, and make informed decisions regarding appropriate interventions.

C. Increase the oxygen flow to 3 L/min.

While increasing the oxygen flow may be a consideration if the client's oxygen saturation is low, it should not be the immediate priority without first assessing the client's respiratory status. Increasing oxygen flow without proper assessment could potentially worsen hypercapnia in some COPD patients and may not address the underlying cause of the client's difficulty breathing. Therefore, this action should be based on assessment findings rather than being the initial response.

D. Have the client cough and expectorate secretions.

Coughing and expectorating secretions can be helpful in clearing the airways and improving breathing in individuals with COPD, especially if secretions are contributing to the difficulty breathing. However, similar to the pursed-lip breathing technique, this action should not be the priority without first assessing the client's respiratory status. The nurse should determine whether secretions are indeed present and causing the difficulty breathing before instructing the client to cough and expectorate. Therefore, this option should follow a thorough respiratory assessment.