A client who had a long-leg cast applied last week reports to the clinic nurse, "I can't seem to catch my breath and I feel a bit lightheaded." Which is the priority action of the nurse?
a. Listen to the client's lungs and check the client's blood glucose level.
b. Give the client 2 L of oxygen via nasal cannula and check vital signs.
c. Check the client's pulse oximetry and ar-range emergency transfer to the hospital.
d. Reassure the client that it takes much more effort to move with a long-leg cast.
C
The client's symptoms are consistent with the development of pulmonary embolism (PE) caused by leg immobility in the long cast. The nurse should check the client's pulse oximetry reading and arrange for transfer to the hospital for further testing and treatment. The client should not be reassured that the symptoms are caused by exertion. The nurse can check vital signs, administer oxygen, and check the client's blood glucose level while waiting for transport to the emergency department.
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