A nurse is receiving morning report when an alarm notifies the nurse that a client with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 89%. The nurse immediately assesses the client, and finds the client resting comfortably in bed on 2 liters of supplemental oxygen via nasal cannula. The client denies distress. Which of the following is the most appropriate nursing action?
Continue to monitor the patient
Silence future alarms
Place the patient on a non-rebreather mask
Increase the oxygen to 4 liters per minute
The Correct Answer is A
A. The client is resting comfortably, denies distress, and has an oxygen saturation of 89% on 2 liters of supplemental oxygen. This is within an acceptable range for many patients with COPD. Given the client's current status, it is appropriate to continue monitoring the oxygen saturation and assess for any changes in condition.
B. While the alarm may be annoying, it is important to keep it active to alert the nurse to any significant changes in the client's oxygen saturation.
C. A non-rebreather mask delivers a higher concentration of oxygen and is typically used in more critical situations. In this case, the client's oxygen saturation is within a safe range, and there is no need to increase the oxygen delivery method.
D. Increasing the oxygen to 4 liters per minute without a clear indication of need could lead to oxygen toxicity, especially in patients with COPD. It is important to titrate oxygen therapy to the lowest level that maintains adequate oxygen saturation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Amlodipine is a calcium channel blocker used to manage hypertension. It is not associated with an increased risk of osteoarthritis. While hypertension itself is a health concern, amlodipine does not directly contribute to the development of OA.
B. Prednisone is a corticosteroid that can lead to various side effects, including bone loss and osteoporosis with long-term use. Although osteoporosis and OA are different conditions, long-term use of corticosteroids can potentially increase the risk of joint issues and contribute to the development or exacerbation of OA due to the impact on joint cartilage and bone density.
C. Warfarin is an anticoagulant used to prevent blood clots in atrial fibrillation. It is not directly associated with an increased risk of osteoarthritis. The primary concerns with warfarin involve bleeding risks rather than joint health.
D. Being Caucasian and having multiple children do not directly contribute to an increased risk of osteoarthritis.
Correct Answer is C
Explanation
A. Elevated potassium levels (hyperkalemia) can occur in chronic kidney disease, as the kidneys struggle to excrete potassium. However, hyperkalemia does not typically cause visible crystals on the skin. It is more associated with cardiac arrhythmias and muscle weakness rather than skin manifestations.
B. Sodium imbalance is common in chronic kidney disease, often leading to fluid retention and hypertension. However, excess sodium does not result in crystal formation on the skin. Sodium issues are more related to fluid balance and blood pressure, not external crystalline deposits.
C. Urea is a waste product formed from the breakdown of proteins and is normally excreted by the kidneys. In chronic kidney disease, urea accumulates in the blood (uremia) because the kidneys cannot effectively filter it out. Urea can be deposited on the skin and form crystals, leading to a condition known as "uremic frost." This is often observed on the forehead or other areas of the skin and is a direct result of excess urea in the body.
D. Creatinine is another waste product filtered by the kidneys. Elevated levels indicate impaired kidney function, but creatinine itself does not form visible crystals on the skin. Elevated creatinine levels are primarily used as an indicator of kidney function rather than a cause of external skin manifestations.
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