The unlicensed assistive personnel (UAP), a student nurse working as a certified nursing assistant, informs the nurse that the client is dyspneic,
has crackles throughout the lung fields bilaterally, has an oxygen saturation of 94%, has a respiratory rate of 52, and is in respiratory distress. Which action by the nurse is the most appropriate?
1. Notify the health care provider.
2. Call the rapid response team.
3. Instruct the UAP to administer oxygen.
4. Assess the client.
Correct Answer: 4
Whereas the UAP is a student nurse who might be knowledgeable and skilled in assessing clients, the nurse is ultimately responsible and accountable for the client's care, and should assess the client prior to acting on the information provided by the UAP. Only after performing an independent assessment could the nurse effectively determine what intervention is needed.
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