A nurse is monitoring a client in the recovery area after a procedure requiring moderate sedation. The client suddenly exhibits shallow breathing with a respiratory rate of 8 breaths per minute and oxygen saturation of 89%. What is the nurse's first action?
Assess airway patency and provide supplemental oxygen as needed.
Document the findings and notify the provider.
Administer a prescribed reversal agent to address respiratory depression.
Increase the IV fluid rate to enhance circulation.
The correct answer is to assess the client's airway patency and provide supplemental oxygen as needed. Respiratory depression is a known risk after moderate sedation. The priority is ensuring the airway is open and sufficient oxygen is being delivered to address hypoxia. Administering a prescribed reversal agent, such as naloxone, may be appropriate for addressing respiratory depression caused by opioids, but this step should follow airway stabilization and oxygen administration. Increasing the IV fluid rate will not resolve respiratory depression or hypoxia. Documenting findings is necessary but should be done after immediate lifesaving interventions are performed. Prioritization using the ABCs (Airway, Breathing, Circulation) underpins correct nursing practice in this situation.
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