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.
You might also like to view...
A nurse is administering analgesia to a 77-year-old female patient who has been diagnosed with herpes zoster (shingles). Which of the following statements about the patient's diagnosis is most accurate?
A) The disease was most likely contracted sexually, earlier in life. B) Antibiotics, coupled with pain control, will be the most likely course of treatment. C) Age-related changes to the immune system likely made the woman particularly susceptible. D) The infectious process exists in the brain even though symptoms are most often felt peripherally.
The nurse instructs an older client with asthma about use of a peak flow meter. The nurse instructs the client to use the meter at which times? Select all that apply.
1. After eating dinner in the evening 2. If feeling like cold symptoms are occurring 3. If wheezing or tightness in the chest occurs 4. In the morning after awakening and in the early afternoon 5. Every day for the first two weeks after medication changes
Before administering any drug, what should you do? (select all that apply)
a. Check the order. b. Wash your hands. c. Instruct the patient that he or she must take the drug. d. Find out the patient's family history. e. Check the patient's identification band. f. Keep drug in container until at the bedside.
Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which of the following drugs would the nurse administer as ordered after repositioning?
A) Oxytoxic agent B) Magnesium sulfate C) Low-dose nitroglycerin D) Terbutaline