A nurse is caring for a postoperative client who reports difficulty breathing and appears visibly anxious. The client has diminished breath sounds in the lower lobes and a respiratory rate of 24 breaths per minute. What is the most appropriate action for the nurse to take first?
Auscultate lung sounds to identify changes.
Elevate the head of the bed to improve breathing.
Assess oxygen saturation with a pulse oximeter.
Administer oxygen at 2 liters per minute via nasal cannula.
The correct answer is to assess oxygen saturation with a pulse oximeter. In a scenario where a client displays signs of respiratory distress, nursing priorities follow the Airway, Breathing, Circulation (ABC) model. Since the client can still speak (indicating a patent airway), assessing the effectiveness of breathing and oxygen delivery through pulse oximetry becomes the priority. This provides objective data to determine the need for oxygen therapy or other interventions.
Other options such as administering oxygen and elevating the head of the bed may be appropriate secondary actions but should follow the assessment of oxygen saturation. Administering oxygen without knowing the saturation level could delay identifying and addressing the underlying issue. Similarly, auscultating lung sounds is a valuable assessment but has lower priority than determining the client’s oxygenation status.
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