The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?
a. Obtain an arterial blood gas to check for carbon dioxide retention.
b. Increase the patient's oxygen until the pulse oximetry is greater than 98%.
c. Lower the head of the patient's bed and insert a nasal airway.
d. Administer a mild sedative and reorient the patient as needed.
ANS: A
Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided.
You might also like to view...
Harriet Powell, age 68, has just been admitted to the oncology unit with a new diagnosis of lung cancer. This is Mrs. Powell's first time being admitted in the hospital, and she knows very little about her diagnosis
Which of the following is the best action that the nurse can take to make Mrs. Powell's transition easier? a. Leave a printout about lung cancer at her bedside b. Administer an antianxiety agent to keep her calm c. Tell her a physician will be in to explain what is going on d. Talk with her about her fears, questions, or concerns
A patient is being tested for HIV using enzyme immunoassay (EIA). The EIA shows antibodies. The nurse expects the health care provider to order what test to confirm the EIA test results?
A) Another EIA test B) Viral load test C) Western blot test D) CD4:CD8 ratio
The Code for Nurses
a. is a binding oath, which tells nurses how to make ethical decisions b. delineates all obligations and responsibilities of the nurse c. supports the concept of respect for all persons d. assists the nurse in formulating a personal belief system
Which safety device is most appropriate for the nurse who conducts home care visits to postpartum mothers?
1. Cellular phone 2. Map of the area 3. Personal handgun 4. Can of Mace