The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?
a. Pulse oximetry reading of 91%
b. Respiratory rate of 26 breaths/minute
c. Use of accessory muscles in breathing
d. Peak expiratory flow rate of 240 L/minute
ANS: C
Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.
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