NCLEX-PN® ExaminationReduction of Risk PotentialHard
A client is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). The LPN notes the client is restless, confused, and has a respiratory rate of 28 breaths/min. The pulse oximetry reading is 88% on 2 L/min of oxygen via nasal cannula. Which action should the LPN take FIRST?
- ANotify the registered nurse (RN) or healthcare provider.
- BIncrease the oxygen flow rate to 4 L/min.
- CAdminister a prescribed as-needed (PRN) bronchodilator.
- DEncourage the client to cough and deep breathe.
Show answer & explanationAnswer & explanation
Correct answer: A. Notify the registered nurse (RN) or healthcare provider.
The client's symptoms (restlessness, confusion, tachypnea, and low SpO2 despite oxygen) indicate worsening respiratory status and potential hypercapnia or severe hypoxemia. These are signs of acute respiratory distress requiring immediate assessment and intervention by the RN or healthcare provider.
Why the other options are wrong
- B. Increasing oxygen without a direct order or further assessment could be detrimental for a COPD client due to the risk of CO2 retention and respiratory drive suppression; this decision should be made by an RN or HCP.
- C. Administering a bronchodilator might be part of the treatment, but the LPN's first action should be to alert the RN or HCP due to the severity of the client's current symptoms indicating decompensation.
- D. While coughing and deep breathing are important, the client's current acute distress (confusion, low SpO2) requires more immediate intervention and escalation of care.
Acute Respiratory Distress Signs
Signs of acute respiratory distress include changes in mental status, increased work of breathing, and significant hypoxemia.
- Restlessness and confusion can indicate hypoxemia or hypercapnia.
- Increased respiratory rate and effort are compensatory mechanisms.
- Requires immediate intervention and escalation of care.
Memory trick: When breathing goes bad, think 'RED ALERT!' for rapid escalation.