A nurse is caring for a client who is experiencing an acute asthma exacerbation. The client is tachypneic, has visible intercostal retractions, and an oxygen saturation of 86% on room air. Arrange the following nursing actions in the priority order they should be performed, from first to last.
- 1Place the client in a high-Fowler's position.
- 2Apply supplemental oxygen via a non-rebreather mask.
- 3Administer a prescribed albuterol nebulizer treatment.
- 4Establish intravenous access and administer prescribed methylprednisolone.
Answer
The correct priority order is to first position the client to maximize lung expansion, then apply oxygen to correct hypoxia, followed by the fast-acting bronchodilator, and finally the slow-acting corticosteroid.
Based on the ABC (Airway, Breathing, Circulation) prioritization framework, the nurse must first implement the fastest interventions that require the least preparation. Positioning the client upright immediately improves breathing mechanics. Applying oxygen directly addresses the life-threatening hypoxia (SpO2 86%). Once these immediate supportive measures are in place, the nurse administers the rapid-acting bronchodilator to open the airways, followed by the slow-acting corticosteroid to address inflammation.
Step-by-Step Solution
Key Concept
Airway, Breathing, Circulation (ABC) prioritization framework for acute respiratory compromise.