A client who is 2 days post-operative following a right hip replacement suddenly complains of stabbing chest discomfort and difficulty breathing. In what chronological order should the practical nurse (PN) perform the following actions?
- 1Reposition the client into a high-Fowler's alignment.
- 2Measure the current oxygen saturation and vital signs.
- 3Initiate prescribed PRN supplemental oxygen therapy.
- 4Communicate the critical findings to the supervising registered nurse.
- 5Document the acute event, interventions provided, and client response.
Answer
The correct sequence is: repositioning the client, assessing vital signs, administering oxygen, escalating to the RN, and documenting the event.
In any acute physiological crisis, the practical nurse must prioritize actions based on the ABCs (Airway, Breathing, Circulation) and the nursing process. The immediate priority is to facilitate breathing by repositioning the client into a high-Fowler's position. Next, rapid assessment of vital signs provides the necessary data to safely implement a PRN oxygen order. Once the client is temporarily stabilized with these initial measures, escalating the situation to the registered nurse ensures advanced care for a potential pulmonary embolism. Documentation is always the final step after client safety is secured.
Step-by-Step Solution
Key Concept
Prioritization of care during acute respiratory distress using the ABC framework and the nursing process