A nurse is caring for a client with COPD (chronic obstructive pulmonary disease) who is receiving 4 liters of oxygen via nasal cannula. The oxygen saturation is 86% and continues to decrease. What should the nurse do first?

A. Administer a PRN inhaler medication and auscultate breath sounds: The immediate priority in this situation is to correct hypoxemia. Auscultation and PRN medication administration are important but secondary to ensuring adequate oxygenation, as oxygen saturation of 86% indicates severe hypoxemia that requires rapid intervention.

B. Immediately notify the provider of the client's oxygenation status: Notifying the provider is important for collaborative management, but the nurse’s first action must address the urgent physiologic threat—low oxygen saturation. Waiting for instructions without intervening could further compromise tissue oxygenation.

C. Titrate the oxygen down to 3 liters and closely monitor the client's response: Reducing oxygen in a patient with worsening hypoxemia could exacerbate oxygen deprivation. Although COPD patients are at risk for CO₂ retention, the immediate concern is life-threatening hypoxemia, and decreasing oxygen would be unsafe.

D. Titrate the oxygen up to 5 liters and closely monitor the client's response: Increasing supplemental oxygen is the immediate priority to raise oxygen saturation and prevent hypoxic injury. Titrating carefully while monitoring ensures that oxygenation improves without unnecessarily exceeding safe limits for a patient with COPD, balancing hypoxemia correction and risk of CO₂ retention.

A. Partial-thickness skin loss involving epidermis and/or dermis: Stage II pressure injuries are characterized by partial-thickness loss of skin, affecting the epidermis and possibly the superficial dermis. The wound may present as a shallow open ulcer with a red or pink wound bed, or as an intact or ruptured blister. The underlying tissue is still protected, and there is no exposure of deeper structures such as muscle, tendon, or bone.

B. Full-thickness skin loss exposing muscle or bone: This finding corresponds to Stage III or Stage IV pressure injuries. Stage III involves full-thickness skin loss with damage or necrosis of subcutaneous tissue, whereas Stage IV extends to muscle, bone, or supporting structures. Stage II wounds do not involve these deeper layers.

C. Eschar obscuring the wound bed: Eschar is necrotic tissue that can cover Stage III or IV pressure injuries, often appearing black, brown, or tan. In Stage II pressure injuries, the wound bed is typically viable and pink, without necrotic tissue obscuring visualization.

D. Intact skin with non-blanchable erythema: This is indicative of a Stage I pressure injury, where the skin remains intact but shows persistent redness or discoloration that does not blanch when pressure is applied. Stage II involves partial-thickness skin loss, which distinguishes it from Stage I.