HESI RN Exit Proctored Exam
A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. The vital signs are assessed as a temperature of 99.6° F (37.5° C), heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mm Hg, and a oxygen saturation 889% on room air. Which action should the nurse implement?
Explanation & Rationale
A. Intubation is not the first step unless the client's respiratory status continues to deteriorate despite oxygen therapy. B. Obtaining a sputum culture may be helpful but does not address the immediate respiratory compromise. C. A nonrebreather mask with 100% oxygen provides high-flow oxygen and is essential for a client with worsening dyspnea and low oxygen saturation. D. A forward-leaning position may help with breathing but does not provide the necessary oxygen support in this acute situation.
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