The nurse entering the client's room notes that the client is sweating and appears to be pale and gasping. The initial action by the nurse is to:

1. Assess the client.
2. Notify the physician.
3. Administer 10L of oxygen per nasal cannula.
4. Reposition the client.


1. Assess the client.

Rationale:
The first step in any decision process is assessment. 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 physician will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be deleterious to the client in some cases, such as if the client has chronic obstructive pulmonary disease. Oxygen may not be helpful. 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.

Nursing

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