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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The nurse completed the incident report at 1600.

Step 1 is to understand the 24-hour clock format. In this format, the hours of the day run 0-23, midnight to midnight.

Step 2 is to convert the time the nurse administered the medication (0900) to the 12-hour clock format. This is 9 a.m.

Step 3 is to add seven hours to this time (the time that passed before the nurse realized a medication error had occurred). 9 a.m. + 7 hours = 4 p.m.

Step 4 is to convert this time back to the 24-hour clock format. 4 p.m. is 1600 in the 24-hour clock format.

A. “I noticed you got angry at me in the operating room when I was handing you the instruments for the procedure.”. B. “I’m concerned about how you expressed your concern in front of the other staff members and the patient. It made me feel uncomfortable in front of them.”. C. “In the future, if you have an issue with how I do things, please pull me aside privately to discuss your concern.”. D. “If we cannot agree on this alternative, we’ll have to escalate this issue.”.

Correct Answer is B

Explanation

Choice A rationale
This statement is more about describing the specific situation (the “D” in DESC) rather than expressing the nurse’s concerns (the “E” in DESC). It’s important to note that the DESC tool stands for Describe, Express, State, and Consequences. In this context, the nurse is merely stating what happened, not expressing how it made them feel or the impact it had on them.
Choice B rationale
This statement accurately represents the “E” component of the DESC tool, which stands for "Express your concerns"12. In this scenario, the nurse is expressing their feelings about the physician’s behavior and its impact on them. They’re stating how the physician’s actions made them feel uncomfortable, especially in front of other staff members and the patient. This is a crucial step in the DESC process as it allows the individual to express their feelings and concerns about the situation.
Choice C rationale
This statement is more aligned with the “S” component of the DESC tool, which stands for "State other alternatives"12. Here, the nurse is suggesting a different way for the physician to express their concerns in the future. While this is an important part of the DESC process, it does not represent the “E” component.
Choice D rationale
This statement represents the “C” component of the DESC tool, which stands for "Consequences stated"12. In this context, the nurse is outlining the potential outcomes if they cannot agree on an alternative approach. While this is a crucial step in the DESC process, it does not represent the “E” component.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse administers medication to a patient at 0900. Seven hours later, the nurse realizes a medication error has occurred and completes an incident report. At what time, in 24-hour clock format, did the nurse complete the incident report?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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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?