While the nurse is giving morning care to a patient who sustained a fractured pelvis and bilateral fractures of the femur in a motorcycle accident yesterday, the patient complains of shortness of breath and is audibly wheezing
An assessment of the oxygen saturation reveals 76%. The initial intervention by the nurse should be to: a. alert the code team.
b. inform the charge nurse.
c. give oxygen at 4 to 5 L/min.
d. raise patient to high Fowler's position.
D
Raising the patient to high Fowler's position is the best initial intervention as it can be done im-mediately. There is no need to notify the code team, and 5 L/min of oxygen is too much. In-forming the charge nurse and giving oxygen at 2 to 3 L/min can be done when the patient has been made more comfortable.
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