medium · NCLEX-RN basic-care
A 74-year-old male client with end-stage chronic obstructive pulmonary disease (COPD) is admitted to the inpatient hospice unit. He is alert but highly anxious, with a respiratory rate of 28/min and accessory muscle use. The continuous pulse oximeter on his finger reads 87% with the alarm enabled.
Which action should the nurse take first?
- Lower the head of the bed to a flat position to maximize pelvic muscle expansion, in this situation.
- Administer the prescribed sublingual morphine sulfate and discontinue the pulse oximetry monitoring.
- Apply a non-rebreather mask at 15 L/min to raise the oxygen saturation above 92%, in this situation.
- Perform a blood draw for arterial blood gas analysis to assess for hypercapnia.
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