During morning rounds, a practical nurse observes that a client with a history of chronic obstructive pulmonary disease (COPD) is visibly struggling to breathe while lying flat in bed. The client appears highly anxious and is using accessory muscles for respiration. Which initial action should the nurse take?
- Assist the client into a high-Fowler's position to maximize lung expansionAnswer
- BAdminister a prescribed mild sedative to help relieve the client's anxiety
- CTurn the client into a right lateral recumbent position and provide a pillow
- DAsk the client to explain why they are feeling anxious this morning
Answer
The correct action is to assist the client into a high-Fowler's position to maximize lung expansion.
Sitting a dyspneic client fully upright (high-Fowler's position) is a fundamental, immediate nursing intervention. It utilizes gravity to drop the abdominal organs away from the diaphragm, allowing the lungs to expand more fully with significantly less effort. This directly addresses the priority need of breathing.
Step-by-Step Solution
Key Concept
Client Positioning for Airway Management