Report increasing lethargy, confusion, or a slowing respiratory rate in a COPD patient, which may signal CO2 retention.
Before you read
Test yourself first: 5 questions
Question 1 of 5
Oxygen is in use in a client's room. Which safety measure should the nurse implement?
Answer: B. Oxygen supports combustion, so the nurse posts no-smoking signs, removes open flames and ignition sources, and avoids flammable products. Allowing candles, smoking, or petroleum-based lubricants near oxygen creates a serious fire hazard. Electrical equipment should be grounded and in good repair.
Question 2 of 5
A client is prescribed warfarin. Which laboratory value should the nurse monitor to evaluate the safety and effectiveness of therapy?
Answer: B. Warfarin therapy is monitored by the prothrombin time and the international normalized ratio (PT/INR); the typical therapeutic INR for most indications is about 2.0 to 3.0. The aPTT monitors heparin, not warfarin. Potassium and amylase are unrelated to anticoagulation monitoring.
Question 3 of 5
Which is a correct action to prevent a fire when oxygen is in use?
Answer: B. Keep oxygen away from open flames, sparks, and heat; post 'no smoking' signs; avoid petroleum products; and ensure electrical equipment is in good repair. Smoking near oxygen risks fire.
Question 4 of 5
A client with schizophrenia experiencing command hallucinations to harm others is admitted to the unit. Which is the priority nursing action?
Answer: B. Command hallucinations directing harm to others pose an immediate safety risk, so the priority is to ensure the safety of the client, other clients, and staff, which may include closer observation, a low-stimulation environment, and reducing access to potential weapons. Group therapy, medication teaching, and discharge planning are appropriate later but do not take precedence over immediate safety during active, dangerous hallucinations.
Question 5 of 5
A client is receiving a sealed internal radiation implant (brachytherapy) for cervical cancer. Which action by the nurse violates radiation safety principles?
Answer: C. The three principles of radiation safety are time, distance, and shielding. A pregnant nurse should NOT be assigned to a client with a radiation implant, so making that assignment violates safety. Limiting time near the client, maintaining maximum distance, keeping a lead container and long forceps available for a dislodged source, and wearing a dosimetry badge are all correct practices.
Keep the streak going with more questions like these, each with a full rationale.
What is oxygen therapy safety?
In patients with chronic CO2 retention (advanced COPD), high-flow oxygen can blunt the hypoxic drive, so it is titrated to the lowest effective level. Memory aid: oxygen does not burn but it makes everything else burn faster.
Key points to remember
- Oxygen supports combustion, so no smoking, open flames, or sparks are allowed near its use.
- Post 'Oxygen in Use / No Smoking' signage and keep oxygen away from heat sources.
- In COPD CO2 retainers, give the lowest effective flow (often 1-2 L/min via nasal cannula) and monitor closely.
- Humidify oxygen at higher flow rates and assess for skin breakdown behind the ears and nares.
- Petroleum-based products around the face are avoided; use water-based lubricant for dry nares.
Nursing priorities
- Remove ignition sources and post no-smoking/oxygen-in-use signs.
- Titrate flow to the prescribed target SpO2 and assess respiratory status frequently.
- Monitor a COPD patient on oxygen for rising drowsiness or a falling respiratory rate.
- Provide humidification at higher flows and pad pressure points to prevent skin breakdown.
Labs & values
Patient teaching
- Do not smoke and keep oxygen away from stoves, candles, and any open flame.
- Use only water-based lubricants on dry nostrils, never petroleum jelly.
- Do not increase the oxygen flow on your own; use the prescribed setting.
Red flags: report now
- Report increasing lethargy, confusion, or a slowing respiratory rate in a COPD patient, which may signal CO2 retention.
- Never permit smoking, candles, or electrical sparks near oxygen, and never use petroleum-based products on the face.
References
Clinical references for this topic
