A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below:
What action by the nurse is the priority?
a.
Assess blood pressure and pulse.
b.
Attach the client to a pulse oximeter.
c.
Have the client rate his or her pain.
d.
Start high-dose steroid therapy.
ANS: A
This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse should assess indicators of cardiac output, including blood pressure and pulse, as the priority. The other actions are also appropriate but are not the priority.
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