A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, "I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone!"
Which action should the nurse take?
a.
Instruct the client to sit in as upright a position as possible.
b.
Add humidity to the oxygen and encourage the client to wear it.
c.
Document the client's refusal, and call the health care provider.
d.
Contact the provider to request an extra dose of the client's diuretic.
ANS: A
The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.
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