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    Hesi rn medical surgical nursing proctored exam

    A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

    Explanation & Rationale

    A. Increasing oxygen flow might seem like an immediate response, but it's crucial to be cautious with oxygen therapy in COPD patients. They often have a chronic CO2 retention issue, and excessive oxygen can sometimes reduce their drive to breathe, potentially worsening their condition. The increase in oxygen should be based on specific clinical guidelines and patient response, rather than an automatic increase. B. Obtaining a stat arterial blood gas (ABG) is an important diagnostic step to evaluate the client’s oxygenation, ventilation, and acid-base status. This can provide critical information on the severity of the dyspnea and guide further treatment. It’s an essential action, particularly in acute dyspnea, as it helps in understanding the underlying cause and tailoring appropriate interventions. C. The client is already in a high-Fowler’s position, which is optimal for improving lung expansion and easing dyspnea. Lowering the bed to a semi-Fowler’s position might not provide additional relief and could potentially worsen the client’s dyspnea. High-Fowler's position is generally preferred for severe dyspnea as it maximizes lung expansion and facilitates breathing. D. Pursed-lip breathing is a helpful technique for managing dyspnea in COPD patients. It helps to prolong exhalation, reduce airway collapse, and improve gas exchange. This technique can provide immediate relief by helping the client control their breathing and reduce feelings of breathlessness.

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