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NCLEX-RN

Category - Reduction of Risk

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A nurse is caring for a client diagnosed with COPD. On assessment, the client is wheezing and his oxygen saturation falls from 90 to 87% in a span of 4 hours. The nurse’s most important action is to:

Further assess breath sounds
Increase oxygen flow rate from 2L/min to 4L/min
Administer albuterol (Proventil)
Administer beclomethasone (Beclovent)

Explanation

Answer - C - Bronchodilators are administered first to relax the bronchial muscles. After 5 minutes, glucocorticoids are administered to reduce edema of the airways. Increasing the oxygen flow rate increases the oxygen levels in the blood which could lead to respiratory depression.

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