A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD):
Arterial Blood Gas Results
Vital Signs
pH = 7.32
PaCO2 = 62 mm Hg
PaO2 = 46 mm Hg
HCO3- = 28 mEq/L
Heart rate = 110 beats/min
Respiratory rate = 12 breaths/min
Blood pressure = 145/65 mm Hg
Oxygen saturation = 76%
Which action should the nurse take first?
a.
Administer a short-acting beta2 agonist inhaler.
b.
Document the findings as normal for a client with COPD.
c.
Teach the client diaphragmatic breathing techniques.
d.
Initiate oxygenation therapy to increase saturation to 92%.
ANS: D
Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the priority.
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