The nurse is planning care for a client with chronic obstructive pulmonary disease (COPD). The client's symptoms are wheezing, tachycardia, increased respiratory rate, coughing up yellow mucus, and a low oxygen level

Question

The highest-priority nursing diagnosis is:
1. Falls, Risk for
2. Knowledge, Deficient
3. Gas Exchange, Impaired
4. Anxiety.

Answer 1

Correct Answer: 3
Rationale 1: The client is at risk of falling, but another diagnosis is a higher priority.
Rationale 2: There is nothing to suggest this client has a knowledge deficit about the condition.
Rationale 3: The client has low oxygen levels. Increasing the level of oxygen in the client's bloodstream is the highest priority.
Rationale 4: Many clients with COPD experience anxiety during an attack. Increasing the level of oxygen in the blood will relieve the anxiety.
Global Rationale: While all of the nursing diagnosis could be applied to patients with COPD, the most critical is Impaired Gas Exchange.