A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. Which is the priority nursing action?
A) Notify the healthcare provider.
B) Complete a thorough cardiopulmonary assessment.
C) Administer 10 L of oxygen per face mask.
D) Reposition the client to help with breathing.
Answer: B
The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. The healthcare provider will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be dangerous to the client in some cases, such as if the client has chronic obstructive pulmonary disease. The client may have simply slipped down in the bed and need repositioning; on the other hand, the client may be in trouble, so making the decision to simply reposition the client without assessment could cause harm.
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