A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30. Which nursing diagnosis is the priority for this patient?
a. Activity intolerance
b. Risk for skin breakdown
c. Impaired gas exchange
d. Risk for infection
ANS: C
The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity.
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