An intubated client has the following assessment data: rhonchi, pulse oximeter – 92%, soft abdomen, heart rate 88, blood pressure 98/54. What is the nurse's first priority?
1. Suction the client.
2. Contact the health care provider.
3. Increase the oxygen.
4. Start dopamine.
Suction the client.
Rationale: The presence of rhonchi suggests the client needs to be suctioned. The other assessment data are of no consequence; therefore there is no need to contact the health care provider or increase the oxygen. The relative hypotension can be caused by the client being ventilated and does not require dopamine for blood pressure support.
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