A patient diagnosed with a femur fracture is experiencing sudden dyspnea, pleuritic chest pain, syncope with movement, cyanosis, tachycardia, and tachypnea. What should be the nurse's first action?
1. Raise the head of the bed (HOB).
2. Administer oxygen per nasal cannula for the cyanosis and dyspnea.
3. Provide reassurance and keep the patient calm by staying with the patient.
4. Evaluate urinary output to assess cardiac output.
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Rationale 1: Raising the HOB to a high Fowler's position facilitates maximum lung expansion and reduces venous return to the right side of the heart, lowering pressure on the vascular system. This intervention should be done first.
Rationale 2: Oxygen therapy will increase the availability of air to the patient, but another intervention should be performed first.
Rationale 3: Staying with the patient will minimize the stress of the situation and reduce oxygen demand. However, another intervention should be performed first.
Rationale 4: Cardiac output will be helpful to assess, but urinary output must be measured by hourly volumes, and unless a catheter is in place, this action is the least important approach to managing cardiac and pulmonary status from possible emboli.
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