A nurse working in the PACU (post-anesthesia care unit)/recovery room unit is monitoring a patient whose vital signs were stable upon arrival from the operating room. The patient’s temperature began to rise steadily the past 20 minutes and continues to rise, the heart monitor shows sinus tachycardia with a rate of 122, the patient’s blood pressure is 86/42, and pulse ox is 88% on 2 L O2 via nasal cannula.
The nurse suspects which genetic condition?

This statement indicates an understanding of the ethical principle of respect for autonomy, which means that the nurse respects the client’s right to make their own decisions about their care and respects their values and beliefs.

Choice A is wrong because “A nurse’s personal values are not considered when making ethical decisions.” This statement contradicts the ethical principle of integrity, which means that the nurse acts in accordance with their personal and professional values and standards.

Choice B is wrong because “A nurse’s behaviors and actions are called values.” This statement confuses values with morals, which are the judgments about behaviors and actions based on personal or societal beliefs.

Choice D is wrong because “Value clarification involves maintaining clinical competency.” This statement confuses value clarification with professionalism, which involves maintaining clinical competency, accountability, and responsibility. Value clarification is a process of self-exploration and reflection that helps the nurse identify their own values and understand how they affect their ethical decisions.

This is the nurse’s priority because it will help determine the severity of the client’s difficulty breathing and guide the appropriate interventions. According to the Mayo Clinic, oxygen therapy for COPD is indicated when there is not enough oxygen in the blood, which can be measured by a pulse oximeter or a blood gas test. Increasing the oxygen flow without assessing the oxygen level could be harmful or ineffective. Having the client cough and expectorate secretions may help clear the airway, but it is not the first action to take. Calling emergency services may be necessary if the client’s condition is life threatening, but it should not be done before assessing the respiratory status.

Choice A is wrong because it does not address the immediate need of assessing the respiratory status and may cause unnecessary panic or delay in treatment.

Choice B is wrong because it does not follow the guidelines for oxygen therapy for COPD, which require a prescription and monitoring of oxygen levels.

Increasing the oxygen flow without assessing the oxygen level could cause oxygen toxicity or suppress the respiratory drive.

Choice C is wrong because it is not the most urgent action to take.

Having the client cough and expectorate secretions may help clear the airway, but it may also increase the work of breathing and worsen hypoxia.

Assessing the respiratory status should come first.

Normal ranges for oxygen saturation are 95% to 100% for healthy individuals and 88% to 92% for most people with COPD. Normal ranges for blood gas tests vary depending on the laboratory, but generally, normal values for arterial blood gas are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, PaO2 80 to 100 mm Hg, HCO3 22 to 26 mEq/L.