An hour after a patient has a thoracentesis, the patient's oxygen saturation is 88, and respiratory rate is 34 . What actions by the nurse are priorities?
a. Raise the head of the bed and call the nursing supervisor.
b. Give oxygen to the patient and notify the physician.
c. Look at the chest excursion and notify respiratory therapy.
d. Open a chest tube insertion kit and notify the patient's family.
B
The patient most likely has a punctured lung and needs respiratory support. He or she must not be left alone. Oxygen is needed, and the physician must be notified immediately. Raising the head of the bed does not increase the flow of oxygen. Further assessment is not a priority until the oxygen is on and either the physician or respiratory therapy is at the bedside. The nurse should not assume that a chest tube will be inserted. The tray must be kept closed until immediately before being used. The physician needs to be called before the family is called.
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