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Difficulty: EasyPhysiological Adaptation

A practical nurse (PN) is caring for an older adult client who is being treated for pneumonia. The client suddenly becomes restless, reports feeling short of breath, and has an oxygen saturation of 87% on room air. What is the priority action for the PN?

  1. A
    Obtain a complete set of vital signs, including the client's temperature.
  2. Elevate the head of the bed and administer prescribed supplemental oxygen.Answer
  3. C
    Administer a prescribed as-needed (PRN) analgesic to help the client relax.
  4. D
    Reassure the client that feeling anxious is a common reaction to being in the hospital.

Answer

Elevate the head of the bed and administer prescribed supplemental oxygen.
The correct action directly addresses the client's acute hypoxia. Restlessness and a low oxygen saturation (87%) are classic signs of inadequate oxygenation. Elevating the head of the bed facilitates maximum lung expansion, and providing supplemental oxygen directly treats the physiological deficit, perfectly aligning with the Airway, Breathing, Circulation (ABC) prioritization framework.

Step-by-Step Solution

1
Identify the client's primary clinical problem based on the provided data.
The client is experiencing sudden restlessness, shortness of breath, and an oxygen saturation of 87%, which indicates acute hypoxia.
Recognizing signs of physiological deterioration is the first step in making safe clinical judgments.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The client has a severe breathing and gas exchange issue that requires immediate, life-saving intervention.
Airway and breathing issues take precedence over routine assessments or secondary symptoms like anxiety.
3
Determine the most appropriate initial nursing action.
Positioning the client upright and applying oxygen directly addresses the breathing compromise.
These actions immediately improve oxygenation and ventilation, stabilizing the client before further assessments are performed.

Key Concept

Acute Hypoxia Recognition and ABC Prioritization
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Topics

Physiological Adaptation

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