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Difficulty: EasyData Collection Techniques

A licensed practical nurse enters a client's room and observes the client sitting upright in bed, visibly gasping for air and appearing extremely restless. When prioritizing initial data collection, which action should the nurse take first?

  1. Measure the client's oxygen saturation, respiratory rate, and observe the work of breathing.Answer
  2. B
    Ask the client to rate the intensity of any chest discomfort on a numerical scale.
  3. C
    Conduct a comprehensive independent physical examination to diagnose the underlying cause of the dyspnea.
  4. D
    Ask the client, "Why are you breathing so fast when you were resting comfortably earlier?"

Answer

The correct action is to measure the client's oxygen saturation, respiratory rate, and observe the work of breathing.
The correct answer accurately applies the ABC prioritization framework to data collection. In any scenario involving sudden shortness of breath, assessing the client's airway and breathing status (respiratory rate, effort, and oxygenation) is the absolute highest priority. This focused data collection falls directly within the PN scope of practice and provides the critical information needed for immediate clinical response.

Step-by-Step Solution

1
Identify the client's primary physiological presentation.
The client is gasping for air and restless, indicating acute respiratory distress.
Recognizing the immediate physiological threat is the first step in clinical decision-making.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
Airway and Breathing assessments take immediate precedence over all other types of data collection.
Without adequate oxygenation, all other assessments and interventions become secondary.
3
Select the appropriate focused data collection technique within the PN scope of practice.
Measuring oxygen saturation and respiratory effort provides vital objective data.
This objective data is immediately necessary to report to the RN or provider for rapid intervention.

Key Concept

Priority Setting in Data Collection (ABC Framework)
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Topics

Data Collection Techniques

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