A client with chronic obstructive pulmonary disease is sitting upright, using accessory muscles, and has an oxygen saturation of 86%. What should the nurse do first?
1Instruct the client in pursed-lip breathing to raise oxygen saturation.
2Apply prescribed oxygen and assess breath sounds and respiratory effort.✓ Correct answer
3Delay oxygen administration due to concern for suppressing respiratory drive.
4Assist the client to lie flat to enhance diaphragmatic excursion.
Explanation
The client has respiratory distress and marked hypoxemia (SpO2 86%). The nurse should apply prescribed oxygen immediately while assessing breath sounds, respiratory effort, and response (option 2). Pursed-lip breathing can help ventilation in COPD but should not delay oxygen for significant hypoxemia. Concern about suppressing respiratory drive is not a reason to withhold oxygen from a hypoxemic client. Lying flat can worsen breathing.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits COPD exacerbation.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor COPD exacerbation, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
COPD — A chronic lung disease that limits airflow and can cause dyspnea.
Accessory Muscles — Neck and chest muscles used when breathing requires extra effort.