A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air.
The patient’s pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse’s priority action?
Auscultate the lung fields to identify any abnormal sounds.
Administer oxygen via a nasal cannula at 8 liters per minute.
Elevate the head of the patient’s bed to an upright position.
Assist the patient to get up to the chair.
The Correct Answer is B
Choice A rationale
While auscultating the lung fields can provide valuable information about the patient’s respiratory status, it is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.
Choice B rationale
Administering oxygen is the most appropriate action for a COPD patient with an oxygen saturation of 89%. This will help increase the patient’s oxygen saturation and alleviate their shortness of breath.
Choice C rationale
Elevating the head of the bed can help improve lung expansion and ease breathing, but it is not as immediately effective as administering oxygen.
Choice D rationale
Assisting the patient to get up to the chair is not the most immediate action needed for a COPD patient with an oxygen saturation of 89%4.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Fatigue is a subjective symptom because it is experienced and reported by the patient. Patients with left-sided heart failure often experience fatigue due to the heart’s inability to pump sufficient blood to meet the body’s needs.
Choice B rationale
Elevated pulmonary capillary wedge pressure is an objective symptom that can be measured and observed by healthcare professionals. It is not something that a patient can directly experience or report.
Choice C rationale
Orthopnea, or difficulty breathing when lying flat, is a subjective symptom as it is based on the patient’s personal experience. However, it is not the best answer in this case because the question asks for the “subjective symptoms,” and fatigue is a more common subjective symptom of left-sided heart failure.
Choice D rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective symptom that can be observed by healthcare professionals. It is not something that a patient can directly experience or report.
Correct Answer is D
Explanation
Choice A rationale
Subjective documentation cannot be quantified. It is based on the patient’s personal experiences and perceptions, which can vary greatly among individuals.
Choice B rationale
A patient’s description is an example of subjective data, not objective data. Subjective data is information that comes directly from the patient and includes their feelings, perceptions, and reported symptoms.
Choice C rationale
Subjective data can incorporate a patient’s emotions. Emotions can provide valuable insights into a patient’s mental and emotional health, which is an important aspect of overall health.
Choice D rationale
A 2-centimeter red wound with exudate is an example of objective data. Objective data is measurable, observable, and can be verified by more than one person.
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