The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea
What is the first action the nurse should take?
a. Review and implement the primary care provider's prescriptions for treatments.
b. Perform a quick physical examination of breathing, circulation, and oxygenation.
c. Gather a thorough medical history, including current symptoms, from the family.
d. Administer oxygen to the patient through a nasal cannula.
B
The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation to determine the type of immediate intervention required. The nurse's assessment should include simple questions about current symptoms. A more thorough medical history can be gathered once the patient's oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physician's orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed.
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