The nurse is performing a rapid assessment for the assigned clients. Which clients require immediate medical assistance? Select all that apply

Question

1. The client is pale and is breathing in a shallow manner.
2. The client's oxygen saturation level is 74% and is dyspneic.
3. The client is rating his pain at a 3 out of a 10 on a pain scale.
4. The client is unable to follow directions.
5. The nurse determines that the client's level of consciousness is decreasing.

Answer 1

Correct Answer: 1, 2, 4, 5
The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention. The client who has an oxygen saturation level of 74% and is dyspneic is exhibiting clinical manifestations associated with cardiovascular problems. This client should receive immediate medical attention. The client who is unable to follow directions should be provided with immediate medical attention. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This client's level of consciousness is decreasing very quickly and indicates a severe problem is occurring. The client who is complaining of only mild pain does not require immediate medical assistance.