Question

The nurse is providing care for a client who was admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). On assessment the nurse finds the client to be pale, short of breath, and their lung sounds reveal rhonchi. What is the best initial action by the nurse?

Answer 1

The nurse should first assess the client's need for supplemental oxygen using a pulse oximeter and provide oxygen if saturation levels are low. Additionally, preparing to collect a sputum sample and contacting the healthcare provider for potential further orders such as a chest radiograph is advised.

Step-by-step explanation:

The best initial action by the nurse for a client admitted with an exacerbation of chronic obstructive pulmonary disease (COPD) who is pale, short of breath, and has rhonchi in their lung sounds would be to assess the client's need for supplemental oxygen. Due to the presence of hypoxemia, as indicated by the pale appearance and shortness of breath, the nurse should use a pulse oximeter to measure the client's oxygen saturation. If the oxygen saturation is low, administering supplemental oxygen is a priority to improve the client's oxygenation status. In addition, the nurse should prepare to collect a sputum sample and consider contacting the healthcare provider for further orders which might include a chest radiograph to assess for complications such as pneumonia.