Read the client scenario and answer question.

COPD patient's chart - Nurse's Note (0800) 84-year-old male client with a chronic obstructive pulmonary disease (emphysema) history is admitted to the inpatient Med surge unit provider today. Upon admission, the client reports unusual increased shortness of breath and fatigue. The client is on 1 liter of oxygen via a nasal cannula; 02 saturation is 93%. The client's respiratory rate is 30 bpm with accessory muscle use, heart rate is 125 bpm, and blood pressure is 127/89 mmHg. The client has a barrel chest and extremities. On call provided paged, pending call back.

Identify listed assessment findings as expected or findings that need to be reported to the provider. Select only one answer per finding.

A. "Are you having any headaches?" : While headaches can be a side effect of medications, this question does not directly assess the effectiveness of baclofen. Baclofen is primarily used to reduce muscle spasms and improve muscle tone.

B. "How has your appetite been?": Changes in appetite can be related to many factors, including medication side effects, but this question does not address the primary purpose of baclofen, which is to manage muscle spasms.

C. "Does your urine look clear or cloudy?": The appearance of urine is not directly related to the effectiveness of baclofen. This question might be more relevant to assessing other conditions or medications that affect the urinary system.

D. "Are you having trouble with spasms?": Baclofen (Lioresal) is prescribed to manage and reduce muscle spasms in conditions like multiple sclerosis. Asking the client about their experience with muscle spasms directly assesses the effectiveness of the medication in managing their symptoms.

A) Assess the client's potassium level:
While electrolyte imbalances, including low potassium, can contribute to symptoms like restlessness or muscle weakness, it is not the first priority in a client with COPD who suddenly becomes restless and anxious. Restlessness and anxiety in this context are more likely to be due to hypoxia (low oxygen levels), hypercapnia (high carbon dioxide levels), or respiratory distress.

B) Check the client's temperature:
An elevated temperature may indicate an infection, such as pneumonia or a respiratory tract infection, which can exacerbate COPD symptoms. However, in the context of sudden restlessness and anxiety, this is less likely to be the most immediate cause. The primary concern should be addressing the potential respiratory issues, such as hypoxia or acute exacerbation, rather than focusing on fever, unless other signs of infection are present.

C) Increase the client's oxygen flow rate to 15 L/min:
While it is important to ensure adequate oxygenation in a client with COPD, increasing the oxygen flow rate to 15 L/min may not be appropriate, as COPD patients are typically at risk for oxygen-induced hypercapnia. These patients often rely on low levels of oxygen to stimulate breathing, and administering high-flow oxygen can suppress their respiratory drive, potentially worsening carbon dioxide retention.

D) Encourage the client to perform pursed-lip breathing:
Pursed-lip breathing is a highly effective technique for COPD patients to help increase oxygenation and decrease the work of breathing. This technique involves the client breathing in through the nose and exhaling slowly through pursed lips, which helps to keep the airways open longer and facilitates the removal of trapped air in the lungs.