A nurse is caring for a client with COPD who is receiving supplemental oxygen at 2 L/min via nasal cannula. The client's oxygen saturation drops to 86% and the client becomes increasingly restless. Which intervention should the nurse implement first?
- A.Increase the oxygen flow rate to 6 L/min
- B.Assess the client's airway and respiratory status, then notify the provider
- C.Administer a PRN bronchodilator immediately
- D.Reposition the client to a high-Fowler position and increase oxygen to 4 L/min
Show answer & rationale
Correct answer
B. Assess the client's airway and respiratory status, then notify the provider
Rationale
B is correct: Assessment comes before intervention (using the nursing process). The nurse must assess the airway and breathing (auscultate breath sounds, observe chest wall movement, assess level of consciousness) to determine the cause of hypoxemia before blindly increasing oxygen. For COPD patients, hypoxic drive is a concern at high flow rates, providing high-flow oxygen without assessment could suppress respiratory drive. A is incorrect: Increasing O2 to 6 L/min without assessment risks suppressing hypoxic drive in a COPD patient. C is incorrect: A bronchodilator may be indicated if the cause is bronchospasm, but assessment must confirm this first. D is incorrect: Repositioning may be part of the intervention but should follow assessment, and increasing oxygen to 4 L/min without assessment carries the same risk.
Key concepts