The respiratory rate of a lethargic 18-year-old client is 32 beats/min. Rank suitable nursing interventions for this client in order of priority
1. Call respiratory therapy.
2. Reassess respiratory rate.
3. Collaborate with provider.
4. Administer an IV sedative.
5. Call for help and start CPR.
6. Assess remaining vital signs.
6, 2, 3, 1
6. The nurse assesses the blood pressure, heart rate, temperature, and SaO2 to provide comprehensive assessment data and to establish baseline data.
2. The nurse reassesses the respiratory rate after a suitable interval to verify tachyp-nea.
3. After completing the nursing assessment, the nurse collaborates with the provider to plan medical therapy and suitable nursing care.
1. Respiratory therapy is likely to be needed after provider collaboration.
4. Administering a sedative can be contraindicated; besides, the assessment is not complete.
5. The nurse can call for help, but the client is not in eminent danger of cardiopul-monary arrest, so CPR is not indicated as long as the client vital signs are within normal limits.
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