NORCET-7 Mains-2024: A patient with COPD complains of dyspnea. The nursing action will be?

NORCET-7 Mains-2024

Medical & Surgical Nursing

Medium

Appeared in: NORCET-7 Mains-2024

Explanation

Pursed-lip breathing is the priority because it is an immediate, non-invasive, and independent nursing action to manage acute dyspnea.
The technique works by creating positive expiratory pressure, which prevents the premature collapse of small airways during exhalation.
This action prolongs the expiratory phase, helping to expel trapped air, which is a primary cause of the sensation of breathlessness in COPD.
It helps the patient gain control over their breathing, which in turn reduces the respiratory rate and alleviates feelings of panic.

Option B: This is a dependent nursing action that requires a physician's order and is not the most immediate intervention a nurse can perform independently.
Option C: Ambulation increases oxygen demand and physical exertion, which would worsen the patient's shortness of breath.
Option D: While assessment is vital, the ABC (Airway, Breathing, Circulation) principle prioritizes a direct intervention to improve breathing when a patient is in active distress. The intervention should not be delayed for a full vital signs assessment.

Clinical Relevance

Nursing practice connection: Use the key finding related to Priority nursing interventions for managing acute dyspnea in a patient with COPD to guide bedside assessment, documentation, and the next nursing action.
Teaching pursed-lip breathing is a fundamental nursing skill that empowers COPD patients with a self-management technique to control acute episodes of dyspnea, reducing anxiety and potentially preventing emergency room visits.
Nurses must prioritize interventions based on the ABCs. For a patient with dyspnea (a 'Breathing' problem), an immediate action to improve ventilation like PLB or positioning often precedes a full assessment.
What if? - If the patient's dyspnea was accompanied by cyanosis, a pulse oximetry reading below 88%, and altered mental status, the priority would shift. The nurse should immediately call for a rapid response team, apply oxygen as per protocol, and place the patient in a high-Fowler's position, as these signs indicate severe respiratory failure requiring urgent medical intervention beyond just PLB.

How to Approach the Question

First, identify the patient's diagnosis (COPD) and the acute problem (dyspnea).
Recall the pathophysiology of dyspnea in COPD, which is primarily air trapping due to airway collapse on exhalation.
Evaluate the options based on nursing priority principles: ABCs (Airway, Breathing, Circulation), independent vs. dependent nursing actions, and patient safety.
Eliminate the unsafe option first. Ambulation increases oxygen demand and is harmful during acute dyspnea.
Compare the remaining options. Pursed-lip breathing is an independent nursing action that directly addresses the air trapping mechanism and can be initiated immediately.
Recognize that administering medication is a dependent action, and a full vital signs assessment, while important, is secondary to a life-saving breathing intervention.

Concept Tested & Keywords

Concept Tested: Priority nursing interventions for managing acute dyspnea in a patient with COPD.
Stem keywords: COPD, dyspnea, nursing action
Lead-in keywords: BEST, MOST RELEVANT CLUE
Clinical cues: Patient has a chronic condition (COPD)
Clinical cues: Patient has an acute symptom (dyspnea)

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 2 p. 41-43

E6 Nursing Fundamentals Taylor p. 724-726