A nurse is conducting a health assessment on a newly admitted patient. The patient appears anxious and begins to speak in a rushed and disorganized manner. Which of the following responses by the nurse demonstrates therapeutic communication?

Rationale:

A. Asking the client to cough every 4 hours is insufficient in response to hypoxemia. Frequent coughing may help clear secretions, but it does not directly improve oxygen saturation and waiting several hours between coughs may delay intervention.

B. Requesting a prescription for an opioid analgesic is not appropriate because opioids can depress respiratory drive, which may worsen hypoxemia. Administering an opioid without respiratory assessment could be dangerous for a client with low oxygen saturation.

C. Encouraging the client to take deep breaths is correct. Deep breathing exercises, including techniques such as incentive spirometry, help expand the lungs, improve alveolar ventilation, and increase oxygenation. This intervention is noninvasive, safe, and directly addresses the low oxygen saturation.

D. Decreasing the head of the bed is incorrect. A supine or flat position can reduce lung expansion and worsen oxygenation. Elevating the head of the bed, or having the client sit upright, promotes better lung expansion and improves oxygen saturation.

Rationale:
A. Capillary refill time does not directly measure oxygenation of arterial blood. Oxygenation is better assessed using tools such as pulse oximetry (SpO₂) or arterial blood gases (ABGs). A delayed refill does not specifically indicate oxygen levels but rather reflects how well blood is reaching peripheral tissues.

B. Normal capillary refill is typically less than or equal to 2 seconds in adults. A refill time of 5 seconds is significantly delayed, indicating that blood is not returning promptly to the capillaries. This suggests decreased peripheral perfusion, which may occur in conditions such as shock, hypovolemia, dehydration, peripheral vascular disease, or decreased cardiac output. This is a clinically important abnormal finding that requires further assessment.

C. Increased capillary blood flow would result in a faster (not slower) refill time, typically under 2 seconds. A 5-second refill clearly indicates the opposite—reduced blood flow to the extremities.

D. A refill time of 5 seconds is not normal. Normal capillary refill indicates adequate circulation and should occur within 2 seconds. A delayed refill is a warning sign of impaired circulation and should not be interpreted as normal.