RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:
Chart the reading at 91%, this is normal for a COPD patient.
Place a non-rebreather on the patient with high flow oxygen.
Call the doctor if the patient is declining.
Sit the patient up and have them breathe deep.
The Correct Answer is D
Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation: In clients with COPD, the secretions tend to be thick and sticky, which makes it difficult to cough up and clear the airway. To promote respiratory hygiene in this situation, the nurse should recommend increasing fluid intake. Adequate hydration helps to thin the secretions, making them easier to expectorate. The client should aim to drink at least 8-10 glasses of water or other fluids per day unless there is a medical reason not to do so.
Decreasing fluid intake (option a) would make the secretions even thicker and more difficult to clear. Taking Tylenol for secretions (option b) is not a recommended intervention as Tylenol is not indicated for thinning of secretions. Range-of-motion exercises (option c) are important to prevent complications such as pneumonia, but they are not directly related to promoting respiratory hygiene in this situation.
Correct Answer is B
Explanation
Daily weights provide a reliable and accurate measure of fluid balance in the body. An increase in weight can indicate fluid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most effective way to monitor for excess fluid volume in this situation.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.