While conducting hourly rounds, a practical nurse (PN) observes that a client with a history of asthma is suddenly leaning forward, visibly distressed, and wheezing audibly. Arrange the following nursing actions in the correct priority sequence from first to last.
- 1Assist the client into a high-Fowler's position.
- 2Apply supplemental oxygen as prescribed.
- 3Administer the prescribed short-acting bronchodilator via nebulizer.
- 4Auscultate lung sounds and measure oxygen saturation.
Answer
The correct sequence prioritizes immediate airway positioning, followed by oxygenation, pharmacological intervention, and finally, reassessment of the client's respiratory status.
In an acute respiratory distress scenario, nursing actions must follow the ABC (Airway, Breathing, Circulation) framework and the nursing process. Assisting the client into an upright position (Airway) is the most immediate action that can be performed in seconds to facilitate lung expansion. Applying oxygen (Breathing) directly addresses hypoxemia. Administering a bronchodilator treats the underlying condition, and finally, reassessment (Evaluation) determines if the interventions were successful.
Step-by-Step Solution
Key Concept
Prioritization of Acute Respiratory Interventions (Airway, Breathing, Interventions, Evaluation)